(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