Prescription request v2

NOTE: Please submit all prescription requests for the same individual in a single form. We highly recommend that you review the instructions for submitting a prescription request.

We do not accept prescription requests from providers not working at the Westchester Institute for Human Development.

All prescription requests will be processed in five (5) business days.

Requests for Dental:
All requests for dental-related prescriptions should be sent to dentalscripts@wihd.org. For oral sedatives, the agency or caregiver should submit the request 2–4 weeks prior to the scheduled appointment. Please include the patient's full name and date of birth in the subject line.

1. Date of request

2a. Patient First Name

2b. Patient Last Name

3. Date of birth

4. Agency name (if applicable)

5a. Office/Home Phone number

5b. Mobile Phone Number

6a. Primary Email

6b. Secondary Email

7a. Name of person making the request

7b. Relationship to Patient

(Example: caregiver, parent, direct service provider (DSP), nurse, etc.)

8. Any other information that you would like us to know?

10. Does the patient need any durable medical equipments (DMEs) or supplies to be refilled? (If not, please do not enter anything below)

For Office Use Only

Please review the requested medications in chart and send task to the appropriate provider

Completed by: Completed by:

Prescription request tasked to (provider name) Prescription request tasked to (provider name)

Date

Add Remove

Notes (THIS IS OPTIONAL):

Please enter your name after you make a note. For example, "The psych request cannot be made because it is a refill medication. (Manny)". Please note that if any prescription requests cannot be processed, YOU HAVE TO DOCUMENT REASON IN THE EMR SYSTEM!

Note:

Add Remove

!!!! PLEASE COMPLETE THIS SECTION TO CONFIRM THAT ALL PRESCRIPTION REQUEST(s) HAS BEEN TASKED !!!!

If this is not complete, the request will still appear on the prescription request list!!!

If you are human, leave this field blank.