Dear ___________________________,
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM PRESCRIPTION VERIFICATION FORM (TO BE COMPLETED BY PHYSICIAN ONLY) PATIENT INFORMATION NAME ________________________________________________________________________________________ Last First Initial DATE OF BIRTH______________ PLACE OF BIRTH ______________ ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: (HOME) _____________ (WORK) _______________ (CELL) _______________ PHYSICIAN INFORMATION NAME ________________________________________________________________________________________ Last First (PRACTICE/SPECIALTY) ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: __________________________________________________________ …
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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES _________________________________________________________________ VI STATE PHARMACEUTICAL ASSISTANCE PROGRAM PRESCRIPTION VERIFICATION FORM (TO BE COMPLETED BY PHYSICIAN ONLY) PATIENT INFORMATION NAME ________________________________________________________________________________________ Last First Initial DATE OF BIRTH______________ PLACE OF BIRTH ______________ ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: (HOME) _____________ (WORK) _______________ (CELL) _______________ PHYSICIAN INFORMATION NAME ________________________________________________________________________________________ Last First (PRACTICE/SPECIALTY) ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: __________________________________________________________________________ A. Please note any health problem, physical impairment, emotional difficulty, behavioral problem, or facts which may limit full participation in our State Pharmaceutical Assistance Program. ________________________________________________________________________ ________________________________________________________________________ B. Patient is subject to allergies: YES (__) NO (__) Codeine____ Sulfa_____ Aspirin______ Other___________________ C. Patient is subject to: __ asthma __ ear ache __ fainting __ tonsillitis __ eye infection __ sensitive skin __ sinus trouble __ frequent colds __ nightmares __ bronchitis __ sleepwalking __ convulsions __ headache __ bed wetting __ kidney problem __ nosebleed __ high blood pressure __ motion sickness __ allergies (describe)_____________ D. Patient wears contact lenses (__) or glasses (___) Medical Conditions and Diagnosis: (Check all that apply) High Blood Pressure _____ Diabetes _____ Arthritis _____ Cancer _____ Heart Lung _____ Other ___________________________________________________ ________________________________________________________ E. To ensure that all patients comply with their medication regimen in a cost contained manner, please provide a list of the patient’s CURRENT prescribed medication and the indication for its use. Medication Strength (mg) SIG Directions Prescribing Doctor Doctor Phone # Pharmacy Company Date NOTE: THE SPAP PROVIDES MEDICATION ASSISTANCE TO SENIORS AGE 60 AND ABOVE; TO ENSURE THAT WE PROVIDE ADEQUATE COVERAGE, WE ENCOURAGE PHYSICIANS TO PRESCIBE GENERICS UNLESS BRAND IS ABSOLUTELY NECESSARY!!!