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NEW request
Non-Formulary Drug Use Request Form (for Patient Specific Use)
trial renewal
annual renewal
Processing Instructions
Non-Formulary Drug Use Process Flow Diagram (page 2), Non-Formulary Drug Use Procedure (FPP-01) and
Special Authorization Guidelines (FPP-02).
Patient Code1:
Date of Birth: (YYYY/MM/DD)
Facility:
Generic Drug name:
Physician:
1.
Dose/Regimen:
Daily Drug Acquisition Cost:
Expected Duration of Therapy:
New Request
Indication for Use/Reason for Prescribing (include references and citations used if applicable):
Relevant Medical History:
Trials of Formulary (or non-formulary) alternatives and outcomes of trials:
Expected Outcome of Therapy/Measures of Success and Future Monitoring Parameters:
Additional Details (as applicable):
2.
Annual Renewal:
Previous approval code:
Update on Client Status/Monitoring Parameters/other detail:
Trial Renewal – initial trial approved duration:
Trial effect/outcome/benefit:
By completing this NF application, the clinical pharmacist confirms that all
appropriate considerations involving the therapy, risk/benefits, and alternative
therapeutic options have been made
3.
Previous approval code:
Condition Met:
Yes
No
THIS SECTION FOR CLINICAL PHARMACIST/PHARMACY PROVIDER USE ONLY
Must be completed prior to submission
Pharmacists Name:
Phone:
Request Date:
Initial Drug Provision Date (the date your facility starting
providing the drug):
THIS SECTION FOR ALBERTA HEALTH SERVICES USE ONLY
Outcome:
Approval Code:
Approval type:(select)
Date:
1
First four letters of surname followed by first two letters of given name.
Revised 14.08.28
Processing Instructions:
1. Pharmacy Provider email to [email protected], OR fax to 943-0232
FPP-A Form Non-Formulary Request, Addition/Deletion to Formulary, and Special Authorization Request
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