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Get Hepatitis C Treatment Medication Precertification Request Form

Patient DOB G. CLINICAL INFORMATION Section 1 - Required clinical information must be completed in its entirety for all precertification requests. Circle current treatment week: 20 22 What is the viral genotype? Check one - Hepatitis C genotype: 0 2 4 6 8 10 12 14 16 18 1 24 2 26 28 3 30 4 32 34 36 38 40 42 44 46 48 Other (specify): No Has the patient had any prior therapy with a pegylated ? (other than the current requested treatment regimen) Yes If y.

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