Form 1349, Drug Utilization Review Board Annual Disclosure

Instructions for Opening a Form: Some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application on your desktop system. Click here for instructions on opening this form.

Effective Date

4/2026
1349.pdf

Instructions

Updated: 4/2026

Purpose

Complete this form:

  1. When initially applying to be a member of the Drug Utilization Review (DUR) board.
  2. Upon your initial appointment to the board.
  3. Each year as part of the annual attestation process.

Transmittal

Initial Application:

Appointment and Annual Attestation:

Questions

Direct any questions about this form to the Vendor Drug Program at the address above.