Summary. Previous studies have indicated that only 26–61% of hepatitis C virus (HCV) antibody-positive patients are referred to specialists who treat HCV. However, these studies were conducted in homogeneous populations and before pegylated interferon and ribavirin became the standard of care for chronic HCV infection. The aims of this study were: (i) to determine the percentage of HCV antibody-positive patients who were referred to specialists for further management in an urban, racially diverse population, (ii) to determine the percentage of referred patients who attend specialty clinics, and (iii) to identify factors that predict referral and follow-up. All patients with a positive HCV antibody test in 2005 were identified by an inquiry of EpicTM, our electronic medical record system. All medical records were reviewed for demographics, location where the test was ordered (inpatient vs outpatient), specialty ordering the test, referral, clinic attendance, detectability of HCV RNA and liver function tests. Univariate and multivariate logistic regression were used to evaluate each variable’s effect on referral and clinic attendance. Overall, 251 of 375 (67%) antibody positive patients were referred to HCV specialists. Of the 251 referrals, 166 (66%) attended at least one specialty clinic appointment. Patients were more likely to be referred if their HCV antibody was ordered in the outpatient setting (77% outpatient vs 38% inpatient, P < 0.001) ordered by a family practitioner (79% FP vs 64% for internal medicine doctor vs 58% for all other specialties, P = 0.01) had detectable RNA (88% detectable vs 65% not detectable vs 23% RNA status not available, P < 0.001) or elevation of alanine aminotransferase (75% elevated vs 56% not elevated, P < 0.001). Location, HCV RNA status and ALT elevation remained significant in a multivariate logistic regression model. These data confirm that up to one-third of HCV antibody-positive patients are not referred to HCV specialists, despite the availability of improved treatment regimens. Additional patients are lost to follow-up after being referred. The reasons for suboptimal referral and specialty clinic attendance rates are probably multifactorial. Institution of reflexive RNA testing for positive antibody tests and additional education of those physicians who encounter HCV-positive individuals may improve both rates.