Services - Division of Public Health SystemsMaine DHHS 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, 'Patient Information.' Fill in the patient's name, date of birth, and medical diagnosis. Ensure all details are accurate for proper processing.
3. Move to Section B, 'Physician Information.' Enter your name, telephone number, mailing address, and the consulting physician's name. This information is crucial for communication.
4. In Section C, document the actions taken to comply with the law. Check the appropriate boxes for each oral request made by the patient and provide comments as necessary.
5. Proceed to Section D to specify the medication prescribed and dosage. Include the date prescribed and pharmacist's details if applicable.
6. Finally, complete Section E regarding medical coverage. Select the principal source of medical coverage for the patient and sign at the bottom before submitting.

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