Get Exception Request For Formulafood - Okgov - Ok

Filling out the Exception Request For FormulaFood form is essential for individuals who need special formulas due to qualifying medical diagnoses. This guide provides clear, step-by-step instructions to help you navigate the form efficiently and ensure all required information is submitted accurately.

Follow the steps to successfully complete the Exception Request for FormulaFood form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the participant's name. Ensure that you write down the full name as registered.
3. Enter the participant’s date of birth in the designated field. This must be completed to verify age eligibility.
4. Record the weight and length/height of the participant in the specified sections. Remember, these measurements should be taken within 30 days of your request.
5. Specify the qualifying diagnosis by clearly describing it in the appropriate section. It's also necessary to include the corresponding ICD code to support the request.
6. Indicate the name of the formula required and the amount needed per day. This information helps assess the specific nutrition needs.
7. Choose the duration for which the formula is requested, specifying one, two, three months, or six months if it’s the sole source of nutrition.
8. Add any relevant comments regarding previous formulas or issues encountered to provide context for your request.
9. Select from the additional supplemental foods options, or note if no foods should be included. This section allows healthcare providers to specify what foods should accompany the formula if applicable.
10. Ensure the healthcare provider signs and prints their name in the designated spaces, along with their phone and fax numbers to facilitate communication.
11. Finally, review all entries for accuracy and completeness. Once confirmed, you can save the changes, download, print, or share the form as needed.

Complete the Exception Request For FormulaFood form online to ensure your request is processed efficiently.