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BUrdYE9DrwgwTLKxhITjxShRhv58dYxLoCwEXwPxLLzfbnCIZZjbz

Referral for Hepatitis C Treatment

Please complete the form to the best of your ability below to provide the information needed for VA HEPC to reach out and begin scheduling a telemedicine appointment or referring to a local provider for treatment if preferred.

Please submit only one referral per person. If you have already submitted a referral and have additional information to provide on the same person, please email it to hepc@sentara.com or fax to 833-596-1646.

Thank you! We will be in touch soon.

Please see our website for additional information www.virginiahepc.com

Date Referred for Treatment:

* must provide value

M-D-Y

Which Best Describes You?

* must provide value

I would like an appointment for treatment for hepatitis C

I am a clinician referring a patient for treatment for hepatitis C

I am a clinician referring from VADOC

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I am Referring For:

* must provide value

Sender's Name:
Referral Location:
Phone:		Email:

First Name:		Last Name:
Date of Birth:		Gender:
Ethnicity:		Race:
		Race:

Medical Insurance Type:

Medical Insurance Number/ Identifier if Known

Insurance Other:

Release Information

DOC ID:

Anticipated Release Date:

M-D-Y

Releasing From:

Will be on Parole?

Yes No

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Parole Office Location?

Preferred Method of Contact:

Best Contact Phone Number:

* must provide value

Secondary Phone Number:

Name/ Relationship of Additional Contact:

Permission to Leave Message with Listed Contact Person?

Yes No

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Permission to Send Email:

Yes No

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Email Address:

Mailing Address:

Street:
City:	State: VA	Zip:

Additional Contact Information:

Expand

Type of Birth Control:

Date First Aware/ Diagnosed with Hepatitis C?
Leave Blank if Unknown.

M-D-Y

Has lab test been done to confirm Hepatitis C virus is in your blood (HCV RNA) after you had the antibody test?

Yes No

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When was the last time this lab (HCV RNA) was done?

Fibroscan Score:

Previous Hepatitis C Treatment?

Yes No

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Name of Treatment Medication:

Start Date of Treatment:

M-D-Y

End Date of Treatment:

M-D-Y

Was the lab to verify cure (SVR) completed after previous treatment?

Yes No

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When is/ was the lab due to verify cure after previous treatment (12 weeks after treatment completion):

M-D-Y

When is the lab (SVR) due to verify cure (12 weeks after treatment completion):

* must provide value

M-D-Y

If you have only had the hepatitis C antibody test done, and have not yet had a lab done to confirm there is hepatitis C virus in your blood, you can go to your local health department to have that confirmatory test done. If you do not have the virus in your blood, you will not need treatment.

If you do need treatment, we will work with you regardless of location within Commonwealth of Virginia or insurance status to get cured. We will ask you to get labs completed, then schedule you for an appointment, if appropriate the doctor will prescribe medication that will be sent to you in the mail. We will be here for you through the whole process to answer any questions.

Where did you have labs drawn? Please give doctor or clinic name and location if known so we are able to obtain a copy of your labs.

Please upload any of the following if available:

Labs Needed	Other, if available:
CBC CMP Hepatitis C Viral Load (RNA) Hepatitis B Surface Antibody Hepatitis B Surface Antigen Hepatitis B Core Antibody IgG Hepatitis A - IgG (total) HIV1/HIV2	Current Medication List Last Clinic Note HAV/ HBV Vaccination Dates Fibroscan Results Ultrasound Results Initial HCV antibody positive date HCV Genotype PT/INR
Additional uploads, if needed:

Upload file

Last Clinic Note with any medical information related to hepatitis C diagnosis or treatment:

Upload file

Our Nursing Team will reach out to you to gather any additional needed information and let you know the next steps to accessing hepatitis C treatment and cure.

Thank you for taking the time to provide this information so we can better assist you!

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