Regular assessment is required to verify the ongoing need for more frequent dispensing, and to determine whether the patient is stabilized and capable of managing 100-day supplies.
Pharmacist’s Name (Print): Khela, Amir
OCP #: 624460
Pharmacy Name: CLOUD PHARMACY
Telephone: 647-748-1337
Address: 55 Dundas St. East
Fax: 647-748-1336
I consent and authorize to have my medication(s) dispensed in reduced quantities from what was originally prescribed, as per the assessment, rationale, and dispensing regimen outlined above.
I consent to have this form sent to the prescriber(s).
Dear Prescriber: This notification is being sent to you to comply with regulations made under the Ontario Drug Benefit Act and policies under the Ontario Drug Benefit program, whereby I am required to notify you in writing with my determination and rationale noted above for your records.
This documentation is valid for a period of 365 days. It is required to be updated annually and, is to be maintained as part of the patient’s permanent pharmacy health record.
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