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DPHHSQAD/CCL120
(Revision 11/19)NONINGESTIBLE
OVER THE COUNTER MEDICATION
AUTHORIZATION FORM
TO BE COMPLETED BY PARENTChilds Name Date of Birth//Program Name
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How to fill out otc med auth form
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01
Start by gathering all the necessary information and documents such as your personal details, medical history, and prescription details.
02
Carefully read and understand the instructions provided on the OTC Med Auth form.
03
Begin filling out the form by entering your personal details including your name, date of birth, address, and contact information.
04
Provide accurate information about your medical history, including any pre-existing conditions or allergies.
05
Fill in the details of your prescription, such as the medication name, dosage, and frequency of use.
06
If required, attach a copy of your prescription to the form.
07
Review the completed form to ensure all the information provided is accurate and legible.
08
Sign and date the form to certify its authenticity.
09
Submit the filled-out form to the appropriate authority or healthcare provider.
Who needs otc med auth form?
01
OTC Med Auth form is needed by individuals who have been prescribed over-the-counter (OTC) medications by their healthcare providers.
02
It may also be required by individuals who wish to seek reimbursement for OTC medications through their health insurance or flexible spending accounts.
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What is otc med auth form?
The OTC med auth form is a document used to authorize the use of over-the-counter medications.
Who is required to file otc med auth form?
Individuals who need to use over-the-counter medications under authorization are required to file the OTC med auth form.
How to fill out otc med auth form?
The OTC med auth form can be filled out by providing personal information, details of the over-the-counter medication needed, and any relevant medical history.
What is the purpose of otc med auth form?
The purpose of the OTC med auth form is to ensure that over-the-counter medications are used safely and appropriately.
What information must be reported on otc med auth form?
The OTC med auth form must include personal details, the specific over-the-counter medication needed, dosage instructions, and any relevant medical conditions or allergies.
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