Get Quantity Limit Exception Form

This guide provides clear, step-by-step instructions for completing the Quantity Limit Exception Form online. By following these directions, users can ensure that all necessary information is accurately submitted.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Quantity Limit Exception Form. The form will open in the online editor.
2. Fill in the prescriber information section. Include your last name, first name, DEA/NPI number, specialty, phone, and fax. Ensure that all fields are completed accurately.
3. Complete the member information section by entering the member's last name, first name, member ID number, and date of birth.
4. In the medication information section, provide the drug name and strength. Then specify the quantity and dosing details.
5. Indicate the diagnosis and the duration of the treatment. Use the provided fields to enter this information.
6. Answer all questions under the Quantity Limit Exception section. Document the diagnosis and ICD-9 code. Confirm whether the patient has demonstrated an inability to achieve results with the recommended FDA approved dosing regimen. If 'yes', provide details of the previously attempted regimen.
7. State whether there is clinical rationale supporting the use of the medication beyond the maximum FDA approved dose. If 'yes', document the rationale.
8. Add any additional comments in the designated section.
9. Sign and date the form. Include the prescriber or authorized signature and the name/title of the authorized medical staff.
10. Once all sections are completed, save changes, and you can choose to download, print, or share the Quantity Limit Exception Form.

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