Get Request For Prescription And Non Prescription Drugs Form

This guide provides a comprehensive overview of how to effectively fill out the Request For Prescription And Non Prescription Drugs Form online. By following these steps, you can ensure that all necessary information is accurately provided, facilitating a smooth submission process.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the document and open it for online completion.
2. Begin with the prescriber information section. Enter the prescriber's profession, full name, and their phone or fax number. This information identifies the health professional making the request.
3. Next, fill out the patient information. Input the patient's name, date of birth, personal health number (PHN), and phone number. If the patient is a minor, include the name of the parent or guardian.
4. Provide details regarding the patient's health challenges and the medical condition being treated in the designated section.
5. In the drug request section, enter the name of the drug being requested (either the generic or brand name). Specify the strength, dosage, and frequency of the medication required.
6. Indicate the desired duration of the prescription in the relevant field.
7. Address whether the patient has previously tried this drug and for how long. Include a description of the results from that trial.
8. Answer the question regarding whether the prescriber can access drug samples for a trial period of at least one month by selecting 'Yes' or 'No.'
9. Respond to whether the prescriber is involved in any formal drug trials with the manufacturer of the requested drug.
10. In the section regarding other drugs or therapeutic approaches tried, describe any alternatives the patient has used and the results of those treatments.
11. Fill out any additional information that may assist the Health Benefits Exception Committee or the AISH Program in making funding decisions. This may include hospitalizations or health complications experienced by the patient.
12. Finally, enter the date (in yyyy-mm-dd format) and ensure the prescriber signs the form, indicating their approval of the request.
13. Once all sections are completed, you can save your changes. If needed, download, print, or share the filled form according to your requirements.

Complete your Request For Prescription And Non Prescription Drugs Form online efficiently today.