Get 12037-b Non-formulary Medication Request Form Wny

This guide provides step-by-step instructions on how to accurately complete the 12037-B Non-Formulary Medication Request Form WNY online. By following these clear and concise steps, users can ensure that their requests are properly documented and submitted for review.

Follow the steps to complete your online request form effectively.

1. Press the ‘Get Form’ button to access and open the 12037-B Non-Formulary Medication Request Form in your selected editor.
2. Begin by entering the required patient information: include the patient's name, date of birth, and identification number in the designated fields.
3. Next, provide the diagnosis and medication requested. Clearly specify the dosage and regimen prescribed by the healthcare provider.
4. Indicate the anticipated duration for the medication request. Note that the maximum duration for approvals is typically one year, but may vary based on specific circumstances.
5. In the justification section, list any other medications the patient has tried, their allergies, or any therapeutic measures previously attempted along with results. Make sure to attach any additional supporting documentation, such as lab reports or test results, if available.
6. Complete the prescriber information: enter the prescriber’s name, specialty, signature, DEA number, telephone number, and NPI number as required.
7. Review all entered information for accuracy. Once confirmed, you may save changes to your document, download it, print it, or share it as necessary.

Submit your completed 12037-B Non-Formulary Medication Request Form online today.