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FORMULARY REQUEST FORM

Instructions: This form must be completed when requesting that a medication be added to the Florida AIDS Drug Assistance Program Formulary. Please provide all information requested below. This form is only available to Florida licensed providers. Any other requests will be discarded.

Please note: Florida has a very broad public records law. Most written communications to or from state officials regarding state business are public records available to the public and media upon request. Your e-mail communications may therefore be subject to public disclosure.

Practicing Physician
License number:
Phone number:
Email address:
Work mailing address:
City:
Generic name of medication:
Trade name of medication:
Manufacturer:
Strength and dosing frequency:
FDA approval date:
FDA approved indication:
Cost implications:
Indication for use in HIV/AIDS patients:
Why should this medication be added to the ADAP Formulary:
 

Important: Please note that this form is available only to Florida licensed providers.

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