Wtc 6

WTC-6
Medication Request Form
Submission Instructions: Please complete this form and send it to the World Trade Center Health
Program at [email protected]. Please do not include any member personally identifiable
information (PII). Incomplete forms will be sent back for more information. Do not fill out WTCHP
Program Section.

Requester Information

Request Date

Choose a CCE/NPN

Requester Name

Requester Title/Role

Requester E-mail

Requester Phone

Clinical Director Name

Clinical Director Signature

Request Urgency

Urgency Rationale

Urgent
Routine

Drug Information

Brand Name of Medication Requested:
Generic Name of Medication Requested:
Is the medication available generically?

Drug Class:

Is this a newly FDA approved medication?
Is this a newly approved indication for a
previously approved medication?
When is this drug indicated during the normal
course of treatment?

1st line
2nd line
Last resort for treatment
Other

If not indicated for the first line therapy then what medications or therapies are indicated for use
prior to this medication?

Does this drug require special monitoring and/
or participation in a patient registration
program?
If so, please explain
Is this an Orphan Drug?
Under what care suit should the drug be added too?
Cancer
Diagnostic
Mental Health
Standard Treatment
Transplant
What WTC health condition(s) does this drug treat?

Please provide information on the drug regimen:
Strengths of medication commercially
available
Dosage forms/route of administration (list all
that apply):
FDA approved direction for use:

Standard length of treatment with this drug:
What is the approximate cost of this
medication per month or course of treatment?
Why does the prescribing provider believe this medication is considered medically necessary?
Please explain:

Narrative: Please provide supporting documentation on the safety and effectiveness of this drug
(package insert, Journal citation, etc:

TO BE FILLED OUT BY WTCHP PROGRAM REVIEWER
Name

Credentials

WTCHP Program Decision

Signature

WTCHP Program Decision Comments