Please fill out this form as completely as possible.
Items in yellow are required.
Requester Information
Requester Name
Requester Email Address
Patient Information
Medicaid ID
First Name
Last Name
Address 1
Address 2
City
State
Zip
DOB
Male
Female Nursing Home Patient
Yes
No
Prescriber Information
Prescriber Medicaid ID
Prescriber Name
Address 1
Address 2
City
State
Zip
Phone
Fax
Pharmacy Information
Pharmacy Medicaid ID
Pharmacy Name
Address 1
Address 2
City
State
Zip
Phone
Fax
Clinical Information
NDC Requested
QTY per month
Drug Name
Strength
Diagnosis Comments
Other Comments or Medical Justification
Reason for Override Request
Early Refill
Maximum Unit / Maximum Cost
Therapeutic Duplication/Brand Limit Switch Over
Early Refill Additional Information
Please select the reason for early refill
Medication Lost
Medication Destroyed
Physician Changed the Dosage
Medication Stolen
Patient going out of town for period greater than the day's supply remaining of the previous refill.
***For lost or stolen medications, a manual PA form with documentation is required.
Max Unit / Max Cost Additional Information
Medical Justification
Therapeutic Duplication / Brand Switch Over Additional Information
Reason for Request
Strength/Dosage change
Switch Over
Drug Name
NDC
QTY
Stop Date
Drug Name
NDC
QTY
Stop Date
Reason for change