Right source pharmacy 2026

1. Click ‘Get Form’ to open the right source pharmacy document in the editor.
2. Begin by entering the Patient Information. Fill in the Member ID, Gender, Date of Birth, First Name, M.I., Last Name, Street Number, Street Name, Apt/Suite #, City, State, ZIP Code, and Phone Number. Ensure all fields are accurately completed.
3. Next, indicate any Allergies by selecting from the options provided or writing in any other allergies if applicable.
4. Proceed to the Prescriber Information section. Enter the Prescriber’s First Name, Last Name, DEA Number, M.I., NPI Number, Street Number, Street Name, Suite #, City, State, ZIP Code, Fax Number and Phone Number.
5. In the Prescription Information section, complete all required fields including Drug Name and Strength, Directions for use, Quantity needed and # of Refills. Remember to initial for DAW if necessary.
6. Finally, ensure that both the Prescriber Signature and Today's Date are filled out. If desired, include a Patient Signature as well.
7. Once completed, fax the form with a cover sheet to RightSourceRx at 1-800-379-7617.

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