Get Nlpdp Special Authorization

The Nlpdp Special Authorization form is a crucial document for obtaining coverage for restricted rheumatoid arthritis medications under the Newfoundland and Labrador Prescription Drug Program. This guide provides clear and concise instructions for successfully completing the form online.

Follow the steps to complete the Nlpdp Special Authorization form online

1. Click ‘Get Form’ button to retrieve the form and access it in the appropriate editor.
2. Begin by entering the patient information, which includes the patient's name, date of birth, NLPDP drug card or MCP number, and their address. Additionally, note the patient's weight in kilograms.
3. For the diagnostic and drug information section, indicate the diagnosis of rheumatoid arthritis and any other relevant conditions. If known, specify the approximate year the patient was diagnosed.
4. In the requested drug name and dose area, select the appropriate medication from the options provided. Options include , , , , and .
5. Document the patient's past medication history by listing each medication the patient has taken, including , IM Gold, , , Chloroquine, D-, , , and any other specifics as required, along with the corresponding dose, date, duration, and outcome of therapy.
6. Detail any drug combinations that have been previously tried, including the length of therapy and the outcome of the treatments (e.g., intolerant, not effective).
7. List the patient’s current therapy, specifying all disease-modifying antirheumatic drugs (DMARDs) and/or biological medications currently being taken, along with their dosages.
8. Provide any additional comments that are relevant, such as NSAID trials or other assessments like BASDAI, ASAS, or HAQ if applicable.
9. Fill out the prescriber information section, including the prescriber's name, address, license number, phone number, and their signature. If needed, include the pharmacist's name and fax number.
10. Review the entire form for accuracy and completeness. Once confirmed, users can save changes, download the file, print it, or share it as necessary.

Complete your Nlpdp Special Authorization form online today!