This book is for your use in obtaining medical services which the Texas Department of Public Welfare makes available to you.

Please help keep it up to date. It will tell the doctor, pharmacist or others you are eligible to receive medical services. It is a health record for you.

Always - Keep your latest Medical Care Identification Card with this book.

Keep your plastic identification card with this book.

Present this book and both cards to your doctor, pharmacist, or others
from whom you request medical services.

Be sure the doctor, pharmacist, or others who provide you with medi
cal help makes his entry in this book and returns the book to you.

TEXAS STATE DEPARTMENT OF PUBLIC WELFARE

INSIDE FRONT COVER

EXHIBIT VIII

When this book is full, mail or take it to your local Texas Department of Public
Welfare office and a new one will be mailed or given to you.

If you lose this book or your plastic identification card, notify your local Texas
Department of Public Welfare office immediately.

This book and plastic identification card are property of the State of Texas and
should be surrendered at request.

(name and strength of drugs currently being taken by recipient)

This Form is to be completed only if an additional prescription (new or refill) results in the recipient exceeding the basic monthly allowable number of prescriptions or the monthly dollar allowable.

The treating physician may complete this form to authorize prescribed medication in excess of the basic allowable or the pharmacist may initiate the form and ask the physician to complete it.

The pharmacist shall mail the completed form to the DPW area Medical Assistance Unit. (See map in front of Texas Medical Assistance Provider Manual for address.) The pharmacist shall hold his claim until the Medical Unit returns the form marked "approved" and assigned an authorization number. Enter the Authorization number on the claim form and submit in the regular billing. In some situations a pharmacist initiated Form 711 may be disapproved. If marked "disapproved" do not bill for. (See Chapter IV, Provider Manual for details regarding pharmacist initiated Prior Authorizations.)

Complete all information as indicated. Recipient information should agree with his current Medical Care Identification Card (Form 86 or 86A).

EXHIBIT X