Get Formulary Addition Request Form - Stonybrookmedicine.edu

The Formulary Addition Request Form is an essential document for requesting additions to the Stony Brook Hospital Drug Formulary. This guide provides a user-friendly walkthrough for completing the form online effectively, ensuring all necessary information is provided accurately.

Follow the steps to complete the Formulary Addition Request Form online.

1. Click ‘Get Form’ button to access the Formulary Addition Request Form and open it in an editable format.
2. Complete all sections of the form; ensure that no fields are left blank to avoid returning it.
3. In the Drug Information section, fill in the required details, including the generic name, manufacturer, indication, trade names, and mechanism of action. Use the gray area to input your text; this gray shading will not appear on the printed document.
4. Provide details about the usual dosage, frequency, duration of therapy, anticipated monthly frequency of use, and the number of patients requiring the medication. Specify the counts for inpatients and outpatients.
5. Indicate the expected cost per patient admission and list any comparable drugs currently on the formulary.
6. Explain the situations where this drug is more effective than those on the formulary and suggest which drugs could be deleted to make room for this addition.
7. Include any special risks, cautions, and restrictions in use, as well as considerations relating to patient safety, such as potential drug interactions.
8. Attach pertinent literature references for review. Fill in suggested criteria for use, including inclusion criteria and monitoring parameters for adverse reactions.
9. In the Miscellaneous Information section, answer the questions regarding involvement in research studies and financial relationships with the drug's manufacturer.
10. Complete the 'Requested by' section with the physician's name, printed name, department/division, and obtain the Chair/Chief's approval by including their signature.
11. After completing the form, review all entries, save changes, and consider downloading or printing the document for submission.

Take the necessary step to enhance the formulary by submitting your completed Formulary Addition Request Form online today.