These interactive forms make sending prescriptions to Avella an easy process. Simply download the form, type or print the appropriate information and fax to Avella. We encourage you to e-prescribe to make the process even easier.

pagefadePrescription Referral Forms

Hepatitis B prescription referral form

Hepatitis C prescription referral form

Proteus Hepatitis C prescription referral form

Once we receive the completed prescription referral form Avella staff will:

  • Verify insurance coverage (including co-pays) and files the claim with the insurance carrier.
  • Provide prior authorization (PA) and financial assistance (FA) support to ensure patient access.
  • Physician and patient are notified of the status of the prescription within 48 hours of receipt.
  • Avella will contact the patient to coordinate delivery of the medication and to review their support services during the course of therapy.
  • After medication is received, an Avella pharmacy will discuss with the patient their medication(s), anticipated side effects and how to contact the pharmacy with any questions.
  • Avella's specialty care coordinators will be a partner for the patient throughout the course of therapy to maintain adherence, monitor and report side effects, and ensure patient access to available resources.