Get Special Authority Form

The Special Authority Form is essential for individuals seeking exemptions for certain medications under the PharmaCare program. This guide provides step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the Special Authority Form online.

1. Click ‘Get Form’ button to access the Special Authority Form and open it in the online editor.
2. In Section 1, provide the prescriber information. Fill in the prescriber's name and mailing address, the application date, and the prescriber’s telephone number, college ID number, and fax number.
3. In Section 2, input the patient information. This includes the personal health number (PHN), date of birth in the format YYYY/MM/DD, and both the family and given names of the patient.
4. In Section 3, detail the medication information. Specify the requested drug exemption and dosage. Indicate whether this is a new request or a renewal.
5. Provide the indication(s) for the special authority. This section covers treatment failure, adverse reactions, drug interactions, and any relevant diagnosis or patient-specific indicators.
6. Ensure both the prescriber’s and the patient’s signatures are added where necessary. The prescriber’s signature is mandatory, while the patient’s signature is optional.
7. After ensuring all sections are filled out correctly, save your changes. You can then download, print, or share the completed form as needed.

Complete your Special Authority Form online today to ensure timely processing of your request.