MassHealth
HIV Resistance Testing Request Form
Laboratory Information
Name:
Address:
Telephone:

Member Information
Name:
RID:

Current antiretrovirals and duration of use
List the current and previous antiretrovirals the member has used and the duration of use, or attach a printout of the member’s medication sheet with this information.

Name of drug
Date ordered
Date ordered

Most recent HIV-RNA: Date of test Result
Most recent CD4 count: Date of test Result
Date HIV first diagnosed: Date of test Result

Reason for ordering HIV Genotype
acute HIV infection
pregnant and HIV positive
planned change in anteretrovirals due to viral rebound
less than six months of established infection, treatment-naive
request for HIV genotype in individual who has not taken HIV
antiretrovirals for more than six months
request for third genotype
request for phenotype

Basis for request (check, and provide further detail if needed)
expectation of resistance in treatment-naive, established infection
history of complex genotype requiring phenotype
incomplete response to treatment initiated since last genotype
need to confirm accuracy of previous resistance test
other (describe)

Physician Signature
The ordering physician must be an HIV specialist or have an HIV specialist recommend the test.

Name of requesting clinician:
Please print 

HIV specialist who recommended this test:
Please print

Signature of requesting clinician
Date

Signature of HIV specialist
Date