F-44126 - Antituberculosis Therapy Program Medication Refill Request printable pdf download

F-44126 - Antituberculosis Therapy Program Medication Refill Request

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

s. 252.10 (7), Wis. Stats.

F-44126 (Rev. 08/08)

(608) 266-9692

FAX: (608) 266-0049

ANTITUBERCULOSIS THERAPY PROGRAM

MEDICATION REFILL REQUEST

Requests for additional medication must be submitted 3-4 weeks before the client needs a refill. Completion of this form is

required. Failure to complete all information requested on this form may delay receipt of medication.

Client Name & Address

Physician Name, Address, & Telephone (Include area code)

Client’s Date of Birth (mm/dd/yyyy)

Local Health Department Name

Date Medication First Ordered (mm/dd/yyyy)

Change in Medicaid Status?

Yes

If yes, check one of the following

Patient no longer on Medicaid

Patient now on Medicaid: MA number*:

__________________________________________

*If patient is now on Medicaid, inclusion of Medicaid number is essential for request processing.

COMPLETE ITEMS BELOW

Medication

Dosage and Frequency

Prescribed Duration of Therapy

Isoniazid (INH)

Rifampin (RIF)

Pyrazinamide (PZA)

Ethambutol (EMB)

Streptomycin (SM)

Other (please specify)

SIGNATURE - Person Completing Request

Date Completed

Print Name

Telephone Number (Include area code)

Return to:

Wisconsin Division of Public Health

TB Program, Room 318

P.O. Box 2659

Madison WI 53701-2659

F-44126 - Antituberculosis Therapy Program Medication Refill Request