Non-Formulary Prescription Form - Kaiser Permanente - Community ... - providers kp 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Member Name and Kaiser Permanente Health Record Number at the top of the form.
3. Fill in the Date of Birth (DOB) and provide your Prescriber’s Name, Phone number, Fax number, and Office Address in the designated fields.
4. Indicate the Diagnosis or Indication for the Non-formulary drug. If applicable, check the box if the member will pay full retail price for this prescription.
5. Complete any relevant sections regarding health record documentation, including lack of efficacy or intolerable side effects with formulary medications.
6. Write down the Non-Formulary Prescription details below, ensuring to specify a pharmacy where the patient desires to pick up their prescription.
7. Finally, have the prescriber sign and date the form before submission.

Start using our platform today to easily complete your Non-Formulary Prescription Form for free!