18003780323 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Step 1: Patient Information. Fill in the patient's name, date of birth, address, phone number, city, state, ZIP code, and CVS Caremark Member ID. Ensure all fields are completed accurately.
3. Proceed to Step 2: Prescription Information. For each prescription, enter the drug name, strength, directions for use, quantity (indicate if it's for 90 days or 1 year), and the number of refills. Repeat this for up to four prescriptions.
4. Move on to Step 3: Physician Information Required. Input the physician's name, phone number, address, fax number, city, state, ZIP code, NPI number, and DEA number if applicable.
5. Finally, in Step 4: Fax this form toll-free to the provided number (1-800-378-0323). Ensure that you have reviewed all information before sending.

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