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Please fax back back to: 713-973-0805
DESTINATION (Required): _____________________ Length of Stay: Departure Date: _______
_____________________ MEDICATION/KIT/SUPPLY REQUESTED:
MED KIT: ______Basic _____Full
* Hydrocodone/Acetaminophen 5/500
Cost Center/PO/SAP#
(Global Santa Fe Employees must indicate Cost Center & SAP #)
PATIENT INFORMATION UPDATE:
NEW MEDICAL PROBLEMS:
CURRENT MEDICATIONS:
Temazapam
* Zolpidem: Ambien CR:
ALLERGIES: ______N ______Y
CHRONIC DISORDERS:
* OTHER: __________________________
__________________________
MEDICATION DELIVERY/PICK-UP
*CONTROLLED SUBSTANCES REPORT
___ Own Pharmacy: ________________________________ ___ Client picking up meds here: Date: ______Time:_____
___ Deliver ** meds to:
____________________________ Date: ______Time:_____ **Delivery Charge depends on destination
___Bill Company: __________________________________ For Internal Use Only:
Non-MD Staff: MAKE SURE ABOVE TRIP DEPARTURE DATE IS COMPLETED BEFORE GIVING TO M.D
How soon does patient need refill?_______________________________________ URGENT?
Outstanding Balance $: Patient
Business Staff:
Given above BALANCE, OK to refill med ___Y___N, OR have patient settle balance
If patient using ABx Pharmacy, should we give med prior to settling Outstanding Balance? MD Section: See above Business Staff Section Refill? Y
MUST MAKE APPT:
M.D. Initials:
___________________________________________________________________________________________________________ If REFILL answer is NO (Business or Pharm/Nursing Staff), write comments or discuss with physician.
Nursing: Reviewed By:
If Rx denied, CONTACTED:
Was a copy of request given to Pharmacist?
N, Rx called in to:
COMMENTS:
N FILLED By:
___Provide Return Office Visit Form to Physician
___ Record in IMC TRACKING LEDGER
under Refills _____ Initials (done)
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HEALTH CARE PROVIDER GUIDE TO FREE OR REDUCED COST SMOKING CESSATION MEDICATION FOR MICHIGAN RESIDENTS If your clients are having a hard time paying for medications that can help them quit smoking, there are programs that may be able to help. Medicaid Michigan ENROLLS is a free program that will help callers find out if they qualify for health care coverage through the Michigan

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___________________________________________________________________________ CLINICAL GUIDELINES for SUBCUTANEOUS INFUSION (HYPODERMOCLYSIS) Clinical Policy Folder Ref No: 16 APPROVED BY: Policy and Guideline Ratification Group (PGRG) Date of Issue: July 2010 Version No: 1.3 Date of review: May 2012 Author: Alison Griffiths. Matron District Nursing NHS South Glouces

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