Get the free Extended Prescription Form - LCC Worker Benefit Plans
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Group Benefits
Authorization for Extended Prescription
Complete this form when you require a supply of medication that exceeds the prescription's maximum days' supply standard allowed by your
contract.
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What is extended prescription form?
Extended prescription form is a document used to extend the expiration date of a prescription beyond the usual duration.
Who is required to file extended prescription form?
Medical practitioners, such as doctors and dentists, are typically required to file the extended prescription form.
How to fill out extended prescription form?
To fill out the extended prescription form, you need to provide the necessary patient and medication details, along with the reason for the extension and the prescribing practitioner's information.
What is the purpose of extended prescription form?
The purpose of the extended prescription form is to allow healthcare providers to extend the duration of a prescription when necessary, providing continued access to medication for patients.
What information must be reported on extended prescription form?
The extended prescription form typically requires reporting of patient information, medication details, the reason for the extension, and the prescribing practitioner's information.
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