Referral for Hepatitis C Treatment

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Required format:

LE5hqb3vjSCUMvecgJkP63LyDBG

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

Today's Date:

* must provide value

M-D-Y

I am Filling This Out For:

* must provide value

Myself (family or friend)

Client (from a facility or organization)

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I am Referring From:

Comprehensive Harm Reduction Center (CHR)

SUD Treatment/ OTP/ Recovery Organization

VDH (from ReLink Program Registry)

VDH (not in ReLink Program Registry)

Jail/ Detention Center

VADOC

Hospital, Clinic, Community Organization, or Other

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VADOC Referral For:

* must provide value

Jail/ Detention Center Referral For:

* must provide value

SUD Treatment/ OTP/ Recovery Organization Type:

Opioid Treatment Program (OTP)

Residential SUD Treatment/Recovery Center

Outpatient SUD Treatment Program

Recovery Support/Other

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HCV treatment plan while engaged with SUD/recovery organization:

Organization's Name:

Organization's City/ County:

CHR Site:

OTP Name, Location:

Residential SUD Treatment Program, Location

Jail/ Detention Center and Location:

Health District:

* must provide value

Who should we follow up with in the organization for this patient:
Best Way to Contact this person:
Phone Number for Follow Up:		Email for Follow Up:

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

Other Name Used for Medical Care or Lab Testing:

Organization Patient ID:

Patient Information

Best Contact Phone Number:	Second Contact Number:
Name/ Relationship 2nd Contact:	Permission Leave Message 2nd Contact:
Email Address:	Permission to Send Email:
Preferred Method of Contact:	Best Time of Day to Call:

Currently Experiencing Homelessness or Housing Instability?

Yes No

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Mailing Address: (Please provide if available)

Street:	City:
State: VA Zip:
Additional Contact Information:

Primary Medical Insurance Type:

Medical Insurance Carrier:

Medical Insurance Number/ Identifier:

Insurance Other:

Release Information

Anticipated Release Date:

M-D-Y

Releasing From:

Will be on Parole?

Yes No

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Parole Office Location?

Does Patient Attend Office Based SUD Treatment?

Yes No Unknown

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Which Clinician/ Organization Does the Patient Go To for Follow-Up?

We want to schedule your hepatitis C care appointment, but we can only do that if we can reach you.

• Please enter the phone and email you check most often.
• If you use voicemail, set it up so we can leave a message.
• We'll call or text within 2 business days.
• If your contact info changes, email Lisa at lxholtzw@sentara.com
or text/call 434-235-0571.

We won't be able to assist you if we can't connect.

Medical History
When were you first told you have hepatitis C?	Has the lab test been done to confirm hepatitis C virus in your blood (HCV RNA)?
Have you previously been treated for hepatitis C?

When was the HCV RNA last done?

Where did you have your lab tests done? If possible, please provide the name and location of the doctor or clinic so we can obtain a copy of your lab results.

Name of Treatment Medication:

Start Date of Treatment:

M-D-Y

End Date of Treatment:

M-D-Y

When is the lab (SVR) due to verify cure after current treatment (4 weeks after treatment completion):

* must provide value

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 (4 weeks after treatment completion):

M-D-Y

Fibroscan or Fibrosis Score:

Type of Birth Control:

The following labs are recommended before starting hepatitis C treatment. If you have any of the following available, please upload them below. If not, don't worry, we can often obtain them for you. You may also securely fax them, or ask your healthcare provider to fax them, to 1-833-596-1646.

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 previous treatment:

Upload file

You're in the right place. We're here to help.

If you need hepatitis C treatment, we can assist you no matter where you live in Virginia. Sentara provides quality care to all patients, regardless of ability to pay.

Our care team will work with you to coordinate any needed lab testing and schedule your appointment. If treatment is appropriate, the doctor will prescribe medication, and our specialty pharmacy will help arrange for it to be mailed directly to you.

You're not doing this alone - we're here to support you every step of the way and answer any questions you may have.

After you submit this form, our team will call or text you within 2-3 business days.

Our Nursing Team will reach out to you to gather any additional information needed and let you know the next steps to accessing hepatitis C treatment and a cure. If you are uninsured, or have Humana Healthy Horizons, you can begin the financial assistance application process here https://www.sentara.com/billing/financial-assistance/medical_groups

If you prefer, once you complete this form, you can contact Andrea at 434-227-9631 between 9 AM and 4 PM Monday through Friday, or email afwashi1@sentara.com to learn more and start your path to a cure. If you do not get an immediate answer, please leave a voicemail or send a text, and your call will be returned as soon as possible.

Thank you for taking the time to provide this information so we can help make hepatitis C a part of your past!

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