Request Form To Authorize Antipsychotic Prescription For Youth 17 And Younger
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1
2M
M
P
P
ARYLAND
EDICAID
HARMACY
ROGRAM
T
: 1-855-283-0876
EL
F
: 1-866-671-8084
AX
R
A
A
P
Y
17
Y
EQUEST TO
UTHORIZE
NTIPSYCHOTIC
RESCRIPTION FOR
OUTH
AND
OUNGER
Prescriber Information
Prescriber Name: __________________ ___________________ ____
Email Address: ______________________________________________
Last name
First name
MI
NPI Number: _________________________ Tel: ___________________
Mailing Address: _____________________________________________
Medical Specialty: _____________________ Fax: __________________
___________________________________________________________
Alternate Contact (if applicable):________________________________
Patient Information
Patient Name: ___________________________________ ____________________________ ____
DOB (mm/dd/yyyy): ___________________
Last name
First name
MI
Height (inches):________ Date:__________
Patient MA #: ___________________________________________________
Male Female
Weight (pounds):_______ Date:_________
DSM Diagnosis
(check all that apply)
ADHD
Obsessive Compulsive Disorder
Substance Related/Addictive Disorder
Autism Spectrum Disorder
Panic Disorder
Tourettes Disorder
Bipolar Disorder
Psychotic Disorder – not schizophrenia
Conduct or Oppositional Defiant Disorder
(specify)_________________________
Other:__________________________
Disruptive Mood Dysregulation Disorder
Post Traumatic Stress Disorder
Generalized Anxiety Disorder
Reactive Attachment Disorder
Non-DSM Disorder
Intellectual Disability
Schizoaffective Disorder
Traumatic Brain Injury
Major Depressive Disorder
Schizophrenia
Target Symptoms
(check all that apply)
Aggression
Hallucinations
Mania
The checked symptoms place the child at risk of:
Anxiety
Hyperactivity
Mood instability
hospitalization
Assault
Impulsivity
Self-injurious behavior
out of home placement
Delusion
Insomnia
Other symptoms (specify):
suspension/expulsion from school
Depression
Irritability
______________________
danger to self
___________________________
danger to others
none of the above
Laboratory Values, ECG and Rating Scale
Fasting Glucose:
Abnormal Involuntary
A
ECG
REQUIRED
BASELINE
IS
FOR ALL PATIENTS RECEIVING ZIPRASIDONE OR IF A PATIENT HAS
:
Date:__________
Movement Scale:
HISTORY OF ANY OF THE FOLLOWING
Value:________
Date:__________
Personal history of syncope, palpitation cardiovascular abnormalities yes no
Fasting Lipids:
Score:________
Positive family history of sudden death/cardiovascular abnormalities
yes no
Date:__________
Hepatic Function:
ECG Results (when applicable)
Triglycerides:__________
Date:__________
Date: ______________
normal QTc value(msec): _______________
LDL:___________
Alk. Phos.:__________
HDL:________________
AST:___________
other ECG abnormality (specify): _____________________________________
ALT:________________
Please provide an explanation for any missing laboratory information: _____________________________________________________________
________________________________________________________________________________________________________________________
Non-Pharmacologic Treatment and Other Clinical Information
The patient is currently receiving non-pharmacologic/psychosocial services.
yes no referred and appointment pending
Please specify the type of non-pharmacologic/psychosocial services: _______________________________________________________
The patient has been recently treated in an inpatient, emergency or crisis setting. yes no
date of discharge __________________
The patient has a history of known abuse or trauma. yes no
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