| [613] | 1 | PSXLBLNR ;BIR/HTW,BAB-CMOP Labels-Non Refillable ;[ 12/18/97 12:48 PM ]
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| 2 | ;;2.0;CMOP;**1,10**;11 Apr 97
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| 3 | TOP W !,?54,COPAY," Days Supply: ",$G(TAYS),?102,"Mfg ________ Lot# ________"
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| 4 | W !,SADD1,?102,"Tech__________RPh__________"
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| 5 | W !,SCITY,", ",SSTATE," ",SZIP
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| 6 | I $G(PSXBAR) S X="S",X2=BAR S X1=$X W ?54,@IOBARON,X2,@IOBAROFF,*13
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| 7 | E W !!!!
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| 8 | W "FORWARDING SERVICE REQUESTED"
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| 9 | I '$G(RENW) G NORENEW
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| 10 | NOREFILL ;NO REFILLS REMAIN PRINT SECTION
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| 11 | W ?54,"* NO REFILLS REMAINING ** PHYSICIAN USE ONLY *"
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| 12 | W ! I $G(REGMAIL)=1 W ?21,"CERTIFIED MAIL"
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| 13 | W ?54,"*Signature:____________________________SC NSC*"
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| 14 | W !,?54,"*Print Name:_________________________________*"
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| 15 | W !,"***CRITICAL MEDICAL SHIPMENT***"
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| 16 | W ?54,"*DEA or VA#_________________Date_____________*"
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| 17 | W ?102,"Routing: MAIL"
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| 18 | W !,?54,"*Refills: 0 1 2 3 4 5 7 8 9 10 11 *"
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| 19 | W ?99,"*",?102,"Days Supply: ",$G(TAYS)," Cap: ",$S($G(CAP):"**NON-SAFETY**",1:"SAFETY")
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| 20 | W !,?54,"***** To be filled in VA Pharmacies only *****"
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| 21 | W ?102,"Isd: ",$G(ISD)," Exp: ",$G(EXPDT)
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| 22 | W !,PNAME,?54,$G(PADD1),?102,"Last fill: ",$G(REFLST)
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| 23 | W !,$G(PADD1),?54,$G(PADD2),?102,"Pat. St ",PSTAT," Clinic: ",CLINIC
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| 24 | W !,$G(PADD2),?54,$G(PADD3),?102,$S($G(WARN)'="":"DRUG WARNING "_$G(WARN),1:"")
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| 25 | W !,$G(PADD3),?54,$G(PADD4)
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| 26 | W !,$G(PADD4),?54,"*Indicate address change on back of this form"
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| 27 | W !,?54,"[ ] Permanent [ ] Temporary until ",$S($G(PTEMP)]"":PTEMP,1:"__/__/__")
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| 28 | BAR I $G(PSXBAR) S X="S",X2=BAR,X1=$X W ?102,@IOBARON,X2,@IOBAROFF,*13
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| 29 | Q
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| 30 | NORENEW W ?54,"*** This prescription CANNOT be renewed ***"
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| 31 | W !?21,$S($G(REGMAIL)=1:"CERTIFIED MAIL",1:""),?54,"*",?96,"*"
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| 32 | W !,?54,"* A NEW PRESCRIPTION IS REQUIRED *"
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| 33 | W !,"***CRITICAL MEDICAL SHIPMENT***",?54,"*",?96,"*"
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| 34 | W !,?54,"***** Please contact your physician *******"
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| 35 | W !,?54,$G(PADD1),?102,"Routing: MAIL"
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| 36 | W !,?54,PADD2,?102,"Days Supply: ",$G(TAYS)," Cap: ",$S($G(CAP):"**NON-SFTY**",1:"SAFETY")
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| 37 | W !,PNAME,?54,$G(PADD3),?102,"Isd: ",$G(ISD)," Exp: ",$G(EXPDT)
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| 38 | W !,PADD1,?54,$G(PADD4),?102,"Last Fill: ",$G(REFLST)
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| 39 | W !,PADD2,?54,"*Indicate address change on back of this form",?102,"Pat. Stat ",PSTAT," Clinic: ",CLINIC
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| 40 | W !,$G(PADD3),?54,"[ ] Permanent [ ] Temporary until ",$S($G(PTEMP)]"":PTEMP,1:"__/__/__")
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| 41 | W ?102,$S($G(WARN)'="":"DRUG WARNING "_$G(WARN),1:"")
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| 42 | W !,$G(PADD4)
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| 43 | I $G(PSXBAR) S X="S",X2=BAR,X1=$X W ?102,@IOBARON,X2,@IOBAROFF,*13
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| 44 | Q
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