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DRUG SPECIAL AUTHORIZATION REQUEST
Please complete all required sections to allow your request to be processed.
PATIENT INFORMATION
PATIENT LAST NAMEFIRST NAMECOVERAGE TYPED ATE OF BIRTH: YYY/MM/ALBERTA
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What is drug special authorization request?
Drug special authorization request is a process where a healthcare provider requests approval from an insurance company or government agency to cover a specific medication that may not be on the regular formulary list.
Who is required to file drug special authorization request?
Healthcare providers, such as doctors or pharmacists, are required to file drug special authorization requests on behalf of their patients.
How to fill out drug special authorization request?
To fill out a drug special authorization request, healthcare providers need to provide detailed information about the patient's medical condition, the prescribed medication, and the reason why the medication is necessary.
What is the purpose of drug special authorization request?
The purpose of drug special authorization request is to ensure that patients receive appropriate and necessary medication coverage, even if it is not on the standard formulary list.
What information must be reported on drug special authorization request?
Information that must be reported on a drug special authorization request includes the patient's medical history, the prescribed medication, the dosage, the frequency of administration, and any relevant lab results or test reports.
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