FORMS WITH INFORMATION MISSING WILL BE RETURNED FOR COMPLETION.
APPROVALS WILL NOT BE CONSIDERED AT DOSES OR DOSING INTERVALS OUTSIDE OF PEI GUIDELINES.
SPECIAL AUTHORIZATION REQUEST
STANDARD SPECIAL AUTHORIZATION
Fax requests to (902) 368-4905 OR mail requests to PEI Pharmacare, P.O. Box 2000, Charlottetown, PE, C1A 7N8
SECTION 1 – PATIENT INFORMATION
PERSONAL HEALTH NUMBER (PHN)
PATIENT (FAMILY) NAME
PATIENT (GIVEN) NAME(S)
DATE OF BIRTH (YYYY/MM/DD)
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PATIENT WEIGHT (kg) PATIENT'S MAILING ADDRESS
SECTION 2 – PRESCRIBER INFORMATION
NAME AND MAILING ADDRESS
APPLICATION DATE
YYYY MM DD
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PRESCRIBER'S TELEPHONE #
AREA CODE
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PRESCRIBER'S FAX #
AREA CODE
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SECTION 3 – MEDICATION DETAIL INFORMATION
REQUESTED DRUG (PLEASE PRINT)
DOSAGE AND FREQUENCY
DIAGNOSIS/INDICATION
REASON FOR REQUEST (PLEASE EXPLAIN)
Contraindication ________________________________________________________________________________________________________________________
Adverse Event ________________________________________________________________________________________________________________________
Therapeutic Failure _____________________________________________________________________________________________________________________
Other ________________________________________________________________________________________________________________________________
OTHER COMMENTS, INCLUDING COPIES OF CULTURE & SENSITIVITY REPORTS FOR ANTIBIOTIC REQUESTS, COPIES OF RELEVANT TEST
RESULTS, AND RELEVANT ADVICE RECEIVED FROM CONSULTANTS/SPECIALISTS (IF APPLICABLE)
PEI Pharmacare may request additional documentation to support this Special Authorization Request. Personal information on this form is collected under section 31(c) of
Prince Edward Island's Freedom of Information & Protection of Privacy (FOIPP) Act as it relates directly to and is necessary for providing services under the PEI High-Cost
Drugs Program.
If you have any questions about this collection of personal information, you may contact the program office at 902-368-4947 or at the address at the top of the form.
_________________________________________________________________________________________________
PRESCRIBER SIGNATURE (REQUIRED) DATE
11HPE15-30354
