Get Medication Request Form - Sunflower State Health

This guide provides clear instructions on completing the Medication Request Form for Sunflower State Health. With simple steps, users can efficiently fill out the necessary information for medication requests, ensuring a streamlined approval process.

Follow the steps to fill out the Medication Request Form with ease.

1. Press the ‘Get Form’ button to obtain the Medication Request Form and open it in your preferred document editor.
2. Begin by filling out Section I, Member Information. Include the required details such as the member’s name, date of birth, and contact information.
3. Proceed to Section II, Prescriber Information. Enter the prescriber’s name, ID number, specialty, and NPI or DEA number.
4. If applicable, provide the insurance details in Section III, Insurance Information. This is for specialty requests only.
5. In Section IV, Medication Requested, specify the drug name, dosage, and route of administration, along with directions and quantity per day.
6. Section V focuses on the diagnosis relevant to the request. Fill in the diagnosis and ICD9 code, and ensure to include diagnostic clinicals as necessary.
7. For specialty requests, complete Section VI, Additional Information, including details such as NDC, weight, height, and lab data.
8. In Section VII, Medication History, indicate whether the member is currently on this medication and provide details on previous treatments.
9. Finally, in Section VIII, Rationale for Request, provide pertinent clinical information and ensure to have the prescriber’s signature and date.
10. Once all sections are completed, save the changes, and download a copy for your records. You can choose to print or share the finalized form as required.

Complete your Medication Request Form online today for timely processing.