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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name and Medical Record Number (MR#) in the designated fields. Ensure accuracy as this information is crucial for processing.
Fill in the Patient Address and Date of Birth (DOB). This helps verify the patient's identity and eligibility for assistance.
In the Medications section, list all required medications clearly. Be specific to avoid any confusion during processing.
Have the prescribing doctor sign and print their name, along with their DEA number and NPI number. This validates the prescription request.
Finally, ensure that a patient sticker is affixed to the form, as it will be void without it. Review all entries for completeness before submission.

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2012	4 Satisfied (40 Votes)
2009	4.3 Satisfied (32 Votes)

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