Tasmanian Health Service
 GPO Box 125, HOBART TAS 7001 Australia
 Ph: 1300 135 513
 Web:  www.dhhs.tas.gov.au		

	Hepatitis C Request for Consultant approval of Treatment Plan 
Clinic:  <Regional Clinic> 
Once completed please return all pages by email or fax to medical clinic in your region.
Please note this form is not a referral for a patient appointment. 
The aim of this form is to enable an appropriate specialist to remotely assess the plan proposed by the prescriber.  
Referrer Details:	
 	
Patient Details:	

Name:	
<DrName>	
Name:	
<PtFullName>	

Address:	
<DrAddress>	
Address:	
<PtAddress>	

Phone:	
<DrPhone>	
Medicare:	
<PtMCNo> / <PtMCLine>	

Fax:	
<DrFax>	
DOB:	
<PtDoB>	

	
THCI (if known):	

Email (optional):	
<DrEmail>	
Phone:  	
<PtPhoneMob> or <PtPhoneH>	

Hepatitis C History and Treatment Experience
Date of HCV diagnosis:	 	
Previous treatment:**	 	
Current Renal Disease:	 	Current HIV:**    	
Current Hepatitis B:**		Include Hepatitis B serology below.**	
	
Current medications including OTC, recreational and herbal - please see section at end of form.  	
Drug interactions have been checked: YES/NO please include print out of advice from www.hep-druginteractions.org	

Laboratory Results (or attach copy of results)	
Test	Date	Result	Test	Date	Result	
HCV genotype			HBsAg			
HCV RNA level			HBcAb			
ALT			HBsAb			
AST#			Haemoglobin 			
Bilirubin			Platelet count			
Albumin			INR			
Creatinine			eGFR			
Elastography or fibroscan ***			ECG (if >50y and ribavirin planned			
Liver ultrasound						

Key:
# 	If fibroscan/elastography is done this is not required.
**	Those with co-infections, previous Hepatitis C treatment, cirrhosis and APRI score >1 should be referred separately to clinic for assessment.
***	Elastography/fibroscan if this is not practicable then please supply APRI Score and AST.
~	List latest medications here.

•	Patients should be monitored during treatment according to the Australian Recommendations for the Management of Hepatitis C Virus Infection: A Consensus Statement 2017 Consensus Statement
•	Information is also available at PBS General Statement www.pbs.gov.au/publication/factsheets/hep-c/hep-c-factsheet-community-based-prescribers.pdf
•	Choice of treatment is based on a number of clinical and virological factors. Please see the Consensus Statement above for guidance
•	Patients must be tested for HCV RNA at least 12 weeks after completing treatment to determine outcome with copies of the results to the regional clinic.
Treatment Choice (Please select one. Highlight the box and type ‘x’)
Genotype	Regimen	Duration	
1	Sofosbuvir plus Ledipasvir 	8 weeks 	12 weeks 	24 weeks 	
1 or 3 	Sofosbuvir plus Daclatasvir	12 weeks 	24 weeks 	plus Ribavirin 	
2	Sofosbuvir plus Ribavirin 	12 weeks 	
1b	Paritaprevir/ritonavir plus Ombitasvir plus Dasabuvir 	12 weeks 	
1a	Paritaprevir/ritonavir plus Ombitasvir plus Dasabuvir plus Ribavirin	12 weeks 	24 weeks 	
1 or 4	Elbasvir plus Grazoprevir	12 weeks 	16 weeks plus Ribavirin 	
All genotypes	Sofosbuvir/velpastasvir	12 weeks 		
~		

Declaration by Referrer (must be a GP or appropriate medical specialist)
I declare all the information provided above is true and correct and that I will monitor treatment according to the above guidelines. 	
Signed: ......................................................    Name: <DrName>    Date: <TodaysDate>	
Patient agreement
I agree that the treatment plan has been explained to me and I will complete the plan as described.  
Avoiding further damage to my liver has been discussed by my Doctor.
(If relevant) I agree that the need for contraception has been discussed with me.  	
Signed: ......................................................    Name: <PtFullName>     Date: <TodaysDate>	
Approval by Specialist experienced in the treatment of HCV
	I agree with the decision to treat this person base on the information provided.   
OR
	I advise that more assessment is required to formulate a treatment plan.  Please refer the patient to Clinic as per the guidelines at THS Outpatient Clinics.	
Signed: ......................................................    Name (print): .............................................  Date: .....................................	

Clinic use only
Date referral received: ……………..………………..	 Previous referral? Yes / No    If yes, date: ………………..……………..
Letter sent: …………………………………………...

Medications:
<SelectedRx>

Please also list non-prescription medications and supplements: 
<Please also list non-prescription medications and supplement>

Pathology:
<Ix>