Get Please Do Not Send This Form To A Patients Employer Or To The Minnesota Department Of Health (mdh)

This guide provides comprehensive, step-by-step instructions on filling out the Please Do Not Send This Form To A Patients Employer Or To The Minnesota Department Of Health (MDH) online. Designed for clarity and ease of use, this guide will help ensure you thoroughly complete the form without confusion.

Follow the steps to effectively complete the form.

1. Click 'Get Form' button to access the form. This will allow you to open the document in a format where you can fill it out digitally.
2. In section A, choose the appropriate option by checking one of the boxes to indicate whether you are submitting a Formulary Exception, a Prior Authorization (PA) Request, or if you are unsure.
3. Complete section A with the payer's name and contact details, including address, phone number, and secure fax number, if applicable.
4. Fill out section B with the patient's information. Provide their name, date of birth, address, health plan or prescription plan details, and ID numbers as required.
5. In section C, input the prescriber's details such as their name, NPI, specialty, and business contact information.
6. Proceed to section D to provide detailed information about the prescription drug being requested including drug name, strength, dosing schedule, and clinical trial information.
7. In section E, fill out the patient's clinical information, including diagnosis related to the medication request, drug allergies, and previous therapies tried and their outcomes.
8. If applicable, complete section F with information about the pharmacy being used for submissions to the Minnesota Department of Human Services, including pharmacy name, provider identifier, phone, and address.
9. Section G is for payer use only. If you are a prescriber, no action is necessary here, but be aware that it will be completed by the payer during their review.
10. Once all relevant sections are completed, review all entries for accuracy. You can then save your changes, download the form, print it, or share it as required.

Complete your documents online with ease today!