Get the free PHC-OTC-Formulary-and-Merchandise-Order-Form-DHCS-041320-FR-Form-26.1
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OvertheCounter Pharmacy Order Form If you have chosen the OvertheCounter (OTC) Merchandise option from PHC California's Health and Wellness Benefit, you may order up to $200 worth of OTC pharmacy
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How to fill out phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261
How to fill out phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261
01
To fill out the phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261, follow these steps:
02
Start by providing your personal information, such as your name, address, and contact details.
03
Indicate your eligibility by selecting the appropriate option for your Medi-Cal status.
04
Provide your Medi-Cal beneficiary number and date of birth.
05
Select the desired products from the formulary list. Enter the quantity, product code, and description for each item.
06
If you seek to order certain non-formulary items, provide their details as well.
07
Calculate the total cost by multiplying the quantity with the unit price for each item.
08
Enter any deductions, including discounts or promotion codes.
09
Calculate the subtotal by subtracting the deductions from the total cost.
10
Indicate the preferred shipping method, either standard or expedited.
11
Sign and date the form to certify the accuracy of the provided information.
12
Finally, submit the form by following the instructions given by the ordering entity.
Who needs phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261?
01
Anyone who is eligible for Medi-Cal and wants to order products from the phc-otc-formulary needs to fill out the phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261. This form is specifically required for individuals who wish to order over-the-counter items and merchandise using their Medi-Cal benefits.
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What is phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261?
The PHC OTC Formulary and Merchandise Order Form DHCS 041320 FR Form 261 is a form used by healthcare providers to order over-the-counter (OTC) medications and merchandise on behalf of patients enrolled in a specific health care program.
Who is required to file phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261?
Healthcare providers participating in the program and managing patient care are required to file this form to ensure the appropriate OTC items are made available to their patients.
How to fill out phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261?
To fill out the form, providers should accurately complete patient information, specify the requested OTC items, ensure all required signatures are present, and submit the form according to the guidelines provided in the instructions.
What is the purpose of phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261?
The purpose of this form is to streamline the process of ordering OTC items specifically for eligible patients, ensuring that they receive necessary medications and supplies efficiently.
What information must be reported on phc-otc-formulary-and-merchandise-order-form-dhcs-041320-fr-form-261?
The form requires reporting of patient details, the specific OTC products requested, quantities needed, provider information, and any required signatures for authorization.
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