Indiana § 16-42-24-7 Use request form

Indiana Statutes

§ 16-42-24-7 — Use request form

Indiana·Title 16 HEALTH·Art. 42 REGULATION OF FOOD, DRUGS, AND·Ch. 24 Drugs: Use of Chymopapain

(a)The state department shall prepare a form for a patient to use to request administration of chymopapain. The form must be substantially in the following form: Patient's name _______________________________ Address _____________________________________ Age ___________ Sex ____________ Name and address of administering physician _____________________________________________ Physical condition diagnosed for medical treatment by chymopapain _____________________________________________ _____________________________________________ My physician has explained the following to me:

(1)That the manufacture and distribution of chymopapain has been banned by the federal Food and Drug Administration.

(2)That there are alternative recognized treatments for the back ailment from which I suffer tha

Free access — add to your briefcase to read the full text and ask questions with AI

(a) The state department shall prepare a form
for a patient to use to request administration of chymopapain. The form
must be substantially in the following form:
Patient's name _______________________________
Address _____________________________________
Age ___________ Sex ____________
Name and address of administering physician
_____________________________________________
Physical condition diagnosed for medical treatment by chymopapain
_____________________________________________
_____________________________________________
My physician has explained the following to me:
(1) That the manufacture and distribution of chymopapain has
been banned by the federal Food and Drug Administration.
(2) That there are alternative recognized treatments for the back
ailment from which I suffer that my physician has offered to
provide for me, including the following: (Here describe)
____________________________________________
____________________________________________
Notwithstanding this explanation, I request the administration of
chymopapain in the medical treatment of the back ailment from
which I suffer.
ATTEST:
______________________________________
Prescribing physician
(b) A copy of the request form shall be sent immediately after
execution to the state department.
[Pre-1993 Recodification Citation: 16-8-10-5.]