New prescription fax form 90-daysupplyand4refills: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Prescriber Information section. Enter the Prescriber Name, DEA #, NPI #, Fax #, and Telephone #. Ensure all details are accurate for seamless processing.
Next, provide Member Information. Input the Prescription drug card holder # and Card holder name. Make sure to include all characters and leave spaces blank.
In the Patient Information section, enter the Patient Name and Date of Birth. Also, fill in the Prescriber Address, City, State, Zip, and Ship to address if applicable.
For the medication details, write or stamp the Drug name, Strength, Quantity needed, and Directions for use clearly in the designated fields.
Indicate the number of medications on this fax as instructed in Step 2 of the form.
Finally, sign and date where indicated. Remember that stamps are not accepted; a handwritten signature is required before faxing.

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