Get Medication Exception Form - Samaritan Health Services - Samhealth

The Medication Exception Form ensures that necessary medications are accessible for patients who may not find them on the standard formulary. This guide provides clear, step-by-step instructions for completing the form accurately online.

Follow the steps to complete the Medication Exception Form successfully.

1. Click ‘Get Form’ button to access the Medication Exception Form and open it in your preferred editor.
2. Begin by providing the patient’s name, date of birth, and member number in the designated fields. This information is crucial for identifying the patient within the health system.
3. Next, fill in the prescriber’s name, contact information, and fax number. Accurate details will facilitate communication throughout the authorization process.
4. Complete the address fields, ensuring the correct city, state, and zip code are recorded. This helps in verifying the location and contact capabilities.
5. Enter the drug name along with the requested strength, specific directions for use, quantity, day supply, and number of refills being requested. Ensure that all details are clearly specified to avoid delays.
6. Indicate if the request is expedited or urgent by checking the appropriate box on the form. This step signifies the urgency of the request.
7. Provide information regarding the patient’s diagnosis in the allotted space, as this is critical for the reviewers to understand the context of the request.
8. Select the anticipated duration of therapy from the options provided (less than a month, one to three months, three months to one year, or lifetime). This helps establish the length of time the medication is needed.
9. If applicable, indicate whether other formulary alternatives have been tried and failed. Provide details on these alternatives, including the dates and outcomes, if applicable.
10. If the patient has experienced issues with formulary alternatives, describe these issues and provide any supporting clinical statements. Attach pertinent medical history or documents to strengthen the request.
11. Finally, have the prescriber sign and date the form to validate the information provided. Ensure that the signature is clear to avoid any processing issues.
12. Once all sections are filled, save changes to the form. You can download, print, or share the completed document as needed.

Complete the Medication Exception Form online today to ensure timely access to necessary medications.