Get Virginia Department Of Health Adap Medication/lab Exception Form - Vdh Virginia

Filling out the Virginia Department of Health Adap Medication/lab Exception Form is essential for those seeking an exception for medication or lab tests. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully fill out the form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editing application.
2. Enter the patient’s full name in the designated field, starting with the last name followed by the first name and middle initial.
3. Input the patient's date of birth in the mm/dd/yy format to ensure proper identification.
4. Fill in the patient's complete address, including the city, state, and zip code, to facilitate communication.
5. Indicate the patient’s age in the provided field to assist in the evaluation process.
6. Select the appropriate gender options by marking either 'male' or 'female.'
7. Choose the patient's race or ethnicity from the provided options to ensure accurate data collection.
8. Fill in the health department phone number and fax number to ensure contact information is available.
9. Identify the local health department Adap contact person by providing their name.
10. Enter the prescribing physician's name and their contact information, including phone and fax numbers.
11. Fill in your name and title in the designated fields as the person completing the form.
12. Indicate the date the form is completed using the mm/dd/yy format.
13. Specify the medication or lab test being requested, and provide a reason for the exception request based on the set criteria.
14. List any other anti-retroviral medications the patient is currently taking, including the name, dose, date started, and date discontinued.
15. Provide the laboratory history, starting with the most recent results. Include at least two results for viral load and CD4 counts, along with the corresponding dates.
16. Review the form for accuracy, ensuring all necessary fields are filled out correctly.
17. Upon completion, you can choose to save the changes, download, print, or share the form as required.

Complete the Virginia Department of Health Adap Medication/lab Exception Form online today.