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COVID-19 Outpatient Therapeutics - Patient Self-Referral Form

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IMPORTANT UPDATES:

Statement regarding Omicron Subvariants

11/21/22 Update: The CDC has reported a rapid increase in the circulation of certain COVID-19 variants in the US that are known to be ineffective to several monoclonal antibody (mAb) therapies for the prevention and treatment of COVID-19. Stanford Health Care has been monitoring these variants of concern within our geographic region and has decided we will no longer offer:

Evusheld for pre-exposure prophylaxis (effective 11/23/22)
Bebtelovimab for treatment (effective 11/21/22)

At this time, we highly encourage you to stay updated with the latest COVID-19 boosters and take necessary precautions (e.g. masking in public indoor areas) to avoid exposure.

If you develop COVID-19, please inform your healthcare provider and fill out the SHC treatment self-referral form below. There are several therapeutics (Paxlovid, remdesivir, molnupiravir) that are still active against these resistant subvariants and are available. A member of the COVID Outpatient Therapeutics team will contact you for the best options for COVID-19 treatment. Thank you for understanding.

Thank you,

The SHC COVID-19 Outpatient Therapeutics Team

Instructions

Please complete this form to be screened for outpatient COVID-19 treatment. Refer to the eligibility requirements listed below. Stanford Health Care reserves the right to select the specific treatment based on medication supply and clinical information available at the time of the referral.

A team member will review your response and contact you via phone or email within 24-48 hours to request additional information, if necessary, and to discuss appropriateness of infusion.

For questions, please call (650) 391-8503 on Monday through Friday between 8:00 am PST and 4:30 pm PST. Any calls received after hours will be returned on the next business day.

Billing

COVID-19 Outpatient Therapeutics at SHC is considered a telemedicine service and may be billed to you or your insurance. Additionally, COVID-19 infusion treatments are no longer covered by the US Government and you may be liable for the total cost. Our Financial Counseling team can provide a Good Faith Estimate and payment options. They can be reached at 650-498-2900 option 2.

Eligibility Requirements

In order to qualify to receive this treatment, you must fall under one of the following two categories:
1. You must be over 18 years old, test positive for COVID-19 with symptom onset within the last 7 days, AND meet one of the criteria below:
  - 50+ years old
  - 18+ years old with comorbidities such as cardiovascular disease, high blood pressure, COPD/other chronic respiratory disease, diabetes, immunosuppressive disease, chronic kidney disease or obesity
You are NOT eligible for this treatment if you are:
- Hospitalized for COVID-19
- Requiring oxygen therapy due to COVID-19
- Requiring an increase in your usual oxygen flow rate due to COVID-19 if you are on chronic oxygen therapy for a non-COVID-related medical condition
- Allergic to any of the ingredients in the medication

First & Last Name

* must provide value

Age

* must provide value

Date of Birth

* must provide value

M-D-Y

Phone Number

* must provide value

Email Address

* must provide value

Are you physically located in the State of California at the time of self-referral?

* must provide value

Yes

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Preferred Language for Communication

* must provide value

Which race do you most closely identify with?

* must provide value

Black/African American

Caucasian

Hispanic/Latino

Asian

Native Hawaiian or Pacific Islander

American Indian

Alaskan Native

Other

If other, please specify:

* must provide value

Please indicate your preferred language for communication

* must provide value

Date when COVID-19 symptoms began

* must provide value

M-D-Y

Please select all of the symptoms that you are experiencing from the following list:

* must provide value

Fever

Cough

Sore throat

Headache

Muscle Pain

Shortness of breath

Gastrointestinal symptoms (nausea, diarrhea, etc.)

Fatigue

No symptoms or none of the above

On what date was your COVID test performed?

* must provide value

M-D-Y

Please upload a copy of your positive COVID-19 test result

Upload file

Height (Feet, inches)

* must provide value

Weight (pounds)

* must provide value

Which most accurately reflects your current COVID-19 vaccination status (e.g. Pfizer, Moderna, Johnson & Johnson, Novavax)?

* must provide value

Unvaccinated OR partially vaccinated (e.g. received one dose or less)

Fully vaccinated (e.g. completed primary series)

Fully vaccinated AND boosted (e.g. completed primary series and received bivalent booster after 9/1/22)

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Primary Care Provider Name

* must provide value

Do you have an allergy to any medications?

* must provide value

Yes

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List the medications that you are allergic to

* must provide value

Do you have any medical conditions besides your current COVID-19 infection?

* must provide value

Yes

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Please check all medical conditions that you have been diagnosed with:

* must provide value

High blood pressure for which you are taking medication

Diabetes

Heart disease (including congenital heart disease)

Chronic kidney disease

COPD

Asthma

Other lung disease

Sickle cell disease

Transplant recipient or waiting for transplant

Cancer

HIV

Pregnancy

Other

Do you have a history of liver disease or liver transplant with no labs in the last 6 months?

* must provide value

Yes

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Do you have end-stage renal disease and/or a need for hemodialysis?

* must provide value

Yes

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Specify your medical condition(s)

Please list any medications that you are currently taking. If none, state "N/A".

* must provide value

Has your doctor prescribed oxygen to help you breathe?

* must provide value

Yes

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Describe your oxygen needs

* must provide value

I needed it before I became infected with COVID-19 and I HAVE NOT used more oxygen due to my infection

I needed it before I became infected with COVID-19 and I HAVE used more oxygen due to my infection

My doctor started oxygen because I was infected with COVID-19

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Would you like to be contacted regarding participation in clinical research involving COVID-19?

* must provide value

Yes

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