Get Medical Exception Form

Filling out the Medical Exception Form online is an essential process for requesting medication exceptions. This guide provides clear steps for completing each section of the form to ensure all necessary information is submitted accurately.

Follow the steps to successfully complete the Medical Exception Form online.

1. Click ‘Get Form’ button to obtain the Medical Exception Form and open it in your preferred online editor.
2. Enter the patient's name in the designated field. This information is crucial for identifying the individual for whom the exception is being requested.
3. Provide the CRDP ID number to help track the request within the Chronic Renal Disease Program.
4. In the 'Name of Product for which Exception Requested' section, write '®'. Additionally, submit current PTH lab values and indicate the date therapy was initiated if this is a new therapy.
5. Select the appropriate treatment modality by checking the box for either Hemodialysis, Peritoneal Dialysis, or Transplant.
6. Detail the diagnosis in the corresponding section to provide the context for the medical exception request.
7. List all CRDP formulary products previously used to treat the condition. For each product, document the duration of therapy and describe the outcome, specifically the failure of prior therapy.
8. Fill in the prescribing physician's name, license number, and telephone number to validate the request.
9. Enter the facility name, address, and telephone number where the request originates.
10. If you wish to receive a status update via email, check the corresponding box and provide the necessary email address, facility ID, and NPI numbers.
11. Obtain the prescribing physician's signature and date the form to complete the request.
12. Once all sections are filled, save your changes, then download, print, or share the completed form as needed.

Complete the Medical Exception Form online to facilitate your request today.