Hep C Patient-Provider Agreement Form

STATE OF WEST VIRGINIA
DEPARTMENT OF HUMAN SERVICES
BUREAU FOR MEDICAL SERVICES

The undersigned has been counseled by their healthcare provider on the following:

Patient Name:(Required)

Check all that apply you've been counseled on:(Required)

The importance of not drinking alcohol or using illicit drugs during and after my treatment for Hepatitis C and that I may be required to submit to a drug screen at the discretion of my healthcare provider.

How to avoid being re-infected with Hepatitis C during and after my treatment.

If the patient has been diagnosed with a Substance Use Disorder, the prescriber has counseled/recommended/encouraged the patient to enroll in a treatment program.

(Male) The importance of using a barrier method of birth control and encouraging my partner to also use birth control.

(Female) The importance of using two forms of birth control (one of which must be a barrier method) while being treated. I agree to have pregnancy tests as ordered by my healthcare provider. I also understand that I must tell my healthcare provider if I do become pregnant.

I agree to complete the entire course of treatment, as well as all associated aboratory tests during and after treatment, as ordered by my healthcare provider.

I agree to IMMEDIATELY notify my prescriber if for any reason I feel that I should stop my treatment. I understand that failure to complete my full course of therapy solely due to actions on my part may result in loss of future coverage through Medicaid.

Who is your provider?(Required)

Patient Signature:(Required)

For the prescriber only(Required)

(Prescriber) I understand that an SVR12 is requested to verify treatment success and that failure to provide these results to Medicaid may result in disqualification of my patient from future coverage.

Provider Signature:

Today's Date(Required)

CAPTCHA