Attachment 3 - IHSC Request for Non-Formulary Medication.pdf
PDF 11 KB Posted
- Attached to
- Detention Services (Denver AOR) Federal contract opportunity
- Solicitation number
- 70CDCR21R00000002
- Issued by
- Immigration and Customs Enforcement
About this file
This document contains a request form for non-formulary medication from the Immigration Health Service Corps (IHSC). The form requests information on the indicated use of the medication, why the formulary alternative cannot be used, whether formulary alternatives were previously tried, and includes sections for approval by the requesting provider, clinical director, medical director, and pharmacist.
The related federal contract opportunity is solicitation number 70CDCR21R00000002 for comprehensive detention and transportation services for the Denver, Colorado Area of Responsibility. The opportunity seeks facilities that can house an estimated population of 1,360 males, females, and transgenders in high, medium, and low custodial settings. The soliciting agency is Immigration and Customs Enforcement.
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Text version
Page 1 of 110/2010IHSC Form 067
Request for Non-Formulary Medication ICE Health Service Corps
Country of Origin:A#:
First Name:Last Name:
Medical Clinic:
DOB:
Sex:
Date of Camp Arrival (DCA):
Date: SPC Name:
Generic and Brand name of non-formulary medication (Including dosage form):
Medication continuance New medicationRequest for (Select one):
Please answer the following questions:
1. Indicated use of this medication:
2. Why must this medication be used instead of IHSC Formulary medication?
3. Have formulary alternatives been tried? (If yes, list with usage results)
Requesting Provider Name:
Clinical Director Approval:
Local Pharmacy's Section:
Cost/bottle:
(Include bottle size)
IHSC Medical Director's Section:
DateMedical Director's Signature
If disapproved, state reason for denial:Approved Disapproved
Pharmacist's Signature:
File details come from the government source that posted it. Updated .