Value Options - Northstar

ValueOptions – NorthSTAR

PSYCHIATRIC / SUBSTANCE ABUSE

Medication Request Form

Member's Name: ____________________________________________________________________

First Middle I. Last

Member's North Star ID Number: _________________________ Date of Birth: _______/_______/______

Physician (Full Name): _______________________________ Office contact: _____________________

Physcician’s address: __________________________________________________________________

*Phone Number: (_____) ______-_____________ Fax Number: (_____) ______-___________________

Requested Medication: _________________________________ Medication Allergies: ____________

Medication Strength_______________ # tabs per day_______________________

Relevant Diagnosis: ___________________________________________________________________

Has the member been on this medication in the past? ____Yes ____No If yes, for how long? _______

Please identify the setting the member was stabilized in if the member is currently taking this medication:

________State Hospital _______Private Practice ______Other ___________________________

Request for Copay Waiver ________ Yes _________ No

Request for Dosage Override _________Yes _________No ___________Dose Requested

Previous Medication History:

Drug Strength and Dose Dates of Therapy Reason for Discontinuing

____________________ _______________ ______________________

Rationale for Request_______________________________________________________________

____________________________________________________________________________________

Physician's Signature: ______________________________________________ Date: ____/____/_____

FAX TO: (866) 247-8751