The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

iwbjErTNDADmq4JGFIgAFccervaI4nXEuBi5joutyV6jhL4cFqMAxaC2CJIBu3Wnpty6iVdYtTsiSMnmQxNjaEKi5sbUcqvmQE9cK938HJYPSujTciFvWpi2yuqjd

MSDH Provider Attestation Form (Sunlenca) Form #1371

Returning?

A A A

For Patients Receiving SUNLENCA® through Mississippi ADAP

The Mississippi AIDS Drug Assistance Program (ADAP) requires that all providers who prescribe
Sunlenca to patients at the Mississippi State Department of Health Pharmacy (MSDH) complete an
attestation form to certify that patients meet the criteria for eligibility.

INSTRUCTIONS: This attestation form is to be completed, signed, and dated by the prescriber.

****Sunlenca cannot be dispensed from MSDH Pharmacy until this form is completed and submitted to the Mississippi ADAP for review.****

Thank you!

For questions about this form, contact MSDH Pharmacy at 601-713-3457.

Page 1 of 5

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.