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Get and Sign for Formulary Information and to Download Additional Forms, Please Visit Httpwww 2016-2022

Get and Sign for Formulary Information and to Download Additional Forms, Please Visit Httpwww 2016-2022

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INFORMATION THAT SHOULD BE CONSIDERED WITH THIS REQUEST Patient s Diagnosis ICD code plus description Medication Requested Strength Dosing Schedule Quantity per Month Is the patient currently treated with the requested medication. Yes No If yes when was treatment with the requested medication started Please list all reasons for selecting the requested medication over alternatives e.g. contraindications allergies or history of adverse drug reactions to alternatives. 243. 6930 6002 ILICP FECR...
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