The doctor completes and signs the form. Must be in blue ink. Patient's Role Must provide a copy of the prior year's tax return and copy of a denial letter from Medicaid or state assistance program. The patient must sign the form. How Dispensed Sent to the doctor's office.
Refills Use a new form.
There is a place on the back of the form to check off that the request is a refill. Limit Indefinite, but the program is meant to be temporary.