Tuberculosis Disease Initial Request For Medication Page 4
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4There are two forms. One for TB INFECTION (F-00905) and the other is for TB DISEASE (F-
44000).
Please make sure you use the correct form for the appropriate diagnosis. A physician may
request medication from the state by completing the appropriate form and submitting it to the
patient’s local health department.
In addition to requiring more detailed testing information significant changes include:
1. Requirement for the patient’s insurance provider and number. MA # if public
insurance.
2. Elimination of multi-vitamin and Vitamin B6 on the TB Infection form, i.e., for
LTBI’s
All fields with an asterisk (*) are required. The following information is required in order to
process a medication order:
patient demographic information specifically including weight, gender, race, ethnicity,
and date of birth
patient’s medication ID number i.e., insurance or MA number
quantifiable test result numbers – dates and induration of TST, the 3 test results Nil, TB
Nil and Mitogen Nil for the QFT-G blood assay
the actual patient risk i.e., reason for referral or treatment
radiographic results (within 6-months of the order)
provider information with signature and date.
Note
Vitamin B-6 is recommended ONLY for those with risk of peripheral neuropathy
(diabetics, malnourished, alcoholics, pregnant or breast-feeding women, etc.). For the
12-week regimen, isoniazid plus rifapentine, vitamin B-6 is only given once-per week
and NOT daily.
Multi-vitamins are not needed unless a patient is malnourished and is reserved for active
TB cases. They are not generally needed for LTBI. Consequently the Initial Request for
Medication form for TB INFECTION (F-00905) has been updated to remove these items.
The IRM will require a physician to specifically order vitamin B-6 or multi-vitamins based
on the risk of peripheral neuropathy or malnutrition.
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