Free 48085.pdf - Indiana

REQUEST FOR TB DRUGS
State Form 48085 (R5 / 10-04) Indiana State Department of Health INSTRUCTIONS: 1. 2. 3. 4. 5. 6. Submit this form to ISDH with the appropriate report form and copy of prescriptions. Do not write patient names or notes on this form. Keep a copy for your records. ISDH Fax number is (317) 233-7747. PCA will send a packing list with the order. Check this list against your copy for accuracy. If a discrepancy is found, please call PCA at (800) 722-0772. See notes at the bottom of the page.

County Name: ___________________________ Address: _______________________________ City: __________________________________ Zip Code: ________________

Date of Request: __________________ Account # (county code): ___________ Nurse's Name: ___________________ Phone Number: ___________________

ITEM NUMBER

DRUG NAME

UNIT OF ISSUE

QUANTITY (of bottles)

A3271-030IS A3269-030IS A3272-016IS B6703-060IS B6702-030IS B6250-060IS A4976-100IS A4975-100IS A6081-100IS A4945-100IS A4200-050IS FLAB-014

Isoniazid 300 mg tabs Isoniazid 100 mg tabs Isoniazid Liquid 50 mg/5ml Rifampin 300 mg caps Rifampin 150 mg caps Pyrazinamide 500 mg tabs Ethambutol 400 mg tabs Ethambutol 100 mg tabs Pyridoxine (Vitamin B6) 50 mg tabs Rifabutin, 150 mg caps*

30 tabs/btl 30 tabs/btl 16 oz. Btl. 60 caps/btl 30 caps/btl 60 tabs/btl 100 tabs/btl 100 tabs/btl 100 tabs/btl 100 caps/btl

____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________

Levofloxacin, 500 mg tabs* 50 tabs/btl Prescription Labels (14 labels/page) Pages Minimum Order 10 pages

NOTES: This form is for local health department use only. For patients who have TB disease or who are TB suspects, submit State Form 14058 "Report of Tuberculosis." Drugs for patients with TB disease will be supplied for a maximum of 6 months at a time. Drugs for TB suspects will only be supplied for the first 3 months of treatment. The balance may be requested once a diagnosis of TB has been made. For patients who are being treated for latent TB infection, submit State Form 49894, "Report of Treatment for Latent TB Infection." Drugs for the entire treatment period should be requested at one time. *Prior approval is required for levofloxacin and rifabutin.