Get Adap Medication Exception Form - Virginia Department Of Health - Vdh Virginia

Completing the ADAP Medication Exception Form is an essential step in accessing necessary medications for individuals living with HIV/AIDS in Virginia. This guide will walk you through each section of the form to ensure accurate and complete submission online.

Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the patient's name in the format of Last, First, and Middle Initial. This information is crucial for identifying the individual requesting the medication.
3. Fill in the date of birth using the format mm/dd/yy. This helps confirm the patient’s age.
4. Provide the complete address of the patient, ensuring accuracy for future correspondence.
5. Indicate the patient's age, which may impact eligibility for certain medications.
6. Select the appropriate sex designation: Male or Female. This information may be relevant for medication recommendations.
7. Enter the city, state, and zip code of the patient's residence.
8. Identify the patient's race/ethnicity by selecting one of the provided options. This demographic information may be relevant for health disparities analysis.
9. List the health department phone number and fax number for communication purposes.
10. Specify the local health department ADAP contact person's name for follow-up questions or clarifications.
11. Input the prescribing physician's name, which is necessary for approving and verifying the medication request.
12. Provide the prescribing physician’s phone and fax numbers for any necessary communications regarding the request.
13. Document who completed the form by entering their name and title.
14. Fill in the date the form is completed using the mm/dd/yy format.
15. Indicate the medication requested, ensuring that it aligns with the needs of the patient.
16. State the reason for the medication exception request, referencing any relevant exception criteria.
17. Detail any other anti-retroviral medications the patient is currently taking, including the name of the medication, dosage, date started, and date discontinued.
18. Provide laboratory history, starting with the most current results. Include at least two viral load results and their corresponding dates.
19. For the VDH use only section, there is space to indicate whether the request is approved or denied, along with a rationale for the decision. This should be completed by the health department staff.
20. Ensure all fields are completed before the final review. Once finished, users can save changes, download, print, or share the form as needed.

Take action now by completing the ADAP Medication Exception Form online.