Get 1199seiu Benefit Funds 90-day Rx Solution Maintenance Drug Access Program Waiver Request Form 2019-2025

Filling out the 1199SEIU Benefit Funds 90-Day Rx Solution Maintenance Drug Access Program Waiver Request Form online can streamline the process of obtaining necessary waivers for medications. This guide will help you navigate the form step-by-step to ensure all required information is provided clearly and accurately.

Follow the steps to complete the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred digital interface.
2. In the 'Request Submitted By' section, enter the name and date you are submitting the waiver request in the designated fields.
3. In the 'Patient Information' section, fill in the member’s full name and member ID number. If the patient is not the member, include the patient's full name and their date of birth.
4. Indicate whether the patient resides at home or at a long-term care facility by checking the appropriate box. Provide the relevant date when the patient became a resident if applicable.
5. Answer whether the patient will be released from the facility and, if so, provide the expected release date in the specified format.
6. Answer questions regarding the nursing home or facility's requirements for blister-packed medications, detailing if their pharmacy participates in the Express Scripts retail pharmacy network.
7. Provide the effective date of the waiver request and a brief explanation of why the waiver is being requested.
8. Complete information regarding the patient's enrollment status in Medicare Part A, Part B, Part D, and Medicaid, including any effective dates where applicable.
9. If applicable, include information for the patient’s designated Power of Attorney, including their name and phone number.
10. Fill in the details of the pharmacy providing blister-packed prescriptions, ensuring you include address, NPI number, and contact information.
11. List all prescription medications for the patient, including name, dosage, and frequency.
12. Complete the nursing home or long-term care facility's information, entering the name, address, and contact details.
13. Ensure the authorized facility administrator signs and dates the form before submission.
14. Finally, save changes, download, print, or share the completed form as necessary. You may send the form via mail or fax to the 1199SEIU Benefit Funds.

Complete your waiver request online today to ensure timely assistance with your medications.