Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the document and open it in your preferred online editor.
2. Begin by entering the patient’s name in the designated field. This information is mandatory.
3. Next, provide the patient’s phone number and patient ID number, which are both required.
4. Fill in the patient’s date of birth to accurately reflect their age.
5. Indicate the patient's sex by selecting either 'Male' or 'Female'.
6. Complete the pharmacy name and optional details such as the pharmacy NABP number, phone number, and fax number.
7. Enter the prescribing physician’s name, which is a required field.
8. Specify the physician's specialty, ensuring this section is adequately filled.
9. If applicable, include the prescriber’s NPI number along with their optional email address.
10. Fill out the physician’s phone number and fax number, both of which are required for contact purposes.
11. Enter the drug requested along with its strength, both of which are necessary entries.
12. Provide the diagnosis that justifies the medication use. This field is mandatory.
13. Optionally specify the formulation and the intended quantity of the medication.
14. Indicate the duration of therapy, days supply, and refills if necessary.
15. Provide directions for the medication, a required field, along with current medications the patient is taking.
16. Detail any previous medications that were tried and failed by the patient, as this information is crucial.
17. Include a medical justification to support the need for the requested medication.
18. Lastly, ensure the requestor's signature is provided along with the request date before submitting.

Encourage others to fill out documents online for a more efficient process.