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PHARMACY REQUEST FOR AN ADJUSTMENT ND DEPARTMENT OF HUMAN SERVICES MEDICAL SERVICES SON 640 (Rev. 06-2002) INSTRUCTIONS: Use one form for each prescription. (1) Reason for Request: A. Underpayment
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How to fill out a pharmacy request for an:

01
Start by obtaining the prescribed medication information from your healthcare provider. This should include the name of the medication, dosage instructions, and any other relevant details.
02
Visit a pharmacy that accepts pharmacy requests for an. Ensure they have the medication in stock or can order it for you.
03
Ask the pharmacist for a pharmacy request form. They should provide you with a form specifically designed for requesting the medication you need.
04
Fill out the pharmacy request form with accurate and complete information. Include your personal details such as your name, contact information, and any relevant medical history.
05
Provide the medication details obtained from your healthcare provider. This may include the medication name, dosage, frequency of administration, and any additional instructions.
06
If applicable, ensure you have a valid prescription from your healthcare provider. Some pharmacies may require a prescription to process your pharmacy request for an.
07
Double-check all the information you have entered on the form to ensure accuracy. Mistakes or incomplete information may lead to delays or errors when processing your request.

Who needs a pharmacy request for an:

01
Patients who have been prescribed medication by their healthcare provider and need to obtain it from a pharmacy.
02
Individuals who require specific medications or treatments that are only available through pharmacies.
03
Those who have previously filled out a pharmacy request for an and need to refill their prescription or request a new supply of medication.
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