2020 Kroger Specialty Pharmacy Urology Referral Form-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date' and 'Need By Date' at the top of the form. Select where to ship the prescription by checking the appropriate box for Patient, Office, or Other.
3. Fill in the 'Patient Information' section with details such as Patient Name, Address, City, State, Zip, Main Phone, Alternate Phone, Social Security Number, Date of Birth, and Gender.
4. Complete the 'Prescriber Information' section with Prescriber Name, Address, City, State, Zip, Phone Number, Fax Number, DEA Number, NPI Number, and License Number.
5. In the 'Clinical Information' section, provide details about Diagnosis and ICD-10 code. Include Serum PSA Level and weight/height measurements. Document any drug allergies and prior failed medications along with their treatment lengths and reasons for discontinuation.
6. For 'Prescription Information', select medications needed by checking the boxes next to each option. Fill in quantities and refills as required.
7. Finally, ensure that both prescriber signatures are completed along with dates before submitting your form.

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