Medical Auth Form

For ordering of pharmaceuticals or legend devices, proper authorization is required from your medical director (or the authorized purchaser and/or agent for your department). Please fill in your agency information below and then forward to your authorizing medical representative to have the form completed and returned to QuadMed, Inc. via fax, mail or email provided in letterhead.

*Agencies ordering controlled narcotics MUST also include a copy of the Medical Director’s DEA Certificate

• Class IV controlled narcotics, such as Valium/Diazepam or Versed/Midazolam, may be ordered via phone, or fax, once the above requirements are on file.

• Class II controlled narcotics, such as Morphine or Demerol/Meperidine, require an original completed Federal DEA Form 222 signed by the Medical Director or properly authorized personnel by Power of Attorney. Form 222 (in triplicate) must be submitted intact, carbons included and the necessary NDC and DEA registration will be completed by the Supplier.

• Agency Name *
• Contact Name *
• Email *
• Phone Number *
• Agency Address *
• City *
• State *
• Zip code *

• (This section is to be completed by your Medical Director) I hereby authorize the internally designated representative of this department to order emergency prescription medications and/or devices, check appropriate box(es):

• Unlimited Standard Emergency Medications and Narcotics: (initial all blanks that apply):

• Class IV Narcotic Substance Authorization of: Valium/Diazepam Versed/Midazolam Other: Class II Narcotic Substance Authorization - the following controlled substances may be listed on DEA Form 222 Morphine Sulfate Demerol/Meperidine Other:

• Unlimited Standard Emergency Medications Authorization: No Narcotics Allowed. Limited Authorization for the following medications only: (List below or attach separate sheet, as needed)

• blanks

• Legend Devices: Items with label/legend stating, “Caution: Federal law restricts this device to sale by or on the order of a physician or an appropriate licensed practitioner”. Items include, but are not limited to: IV Catheters, Needles, Respiratory products and other devices so labeled.

• *To process medication orders, a State License number is required. If ordering Narcotics, a Federal DEA Certificate is also required.

• DEA Number(s) (copy must accompany this form) *
• State License Number (copy must accompany this form) *
• State Controlled License (if required, copy must accompany this form) *
• Physician Printed Name: *
• Physician Signature *
   

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• Telephone Number *
• Email *
• Date *
  - Month - Day Year

  
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