NEW PRESCRIPTION REQUEST FORM - StayWell Guam 2026

1. Click ‘Get Form’ to open the NEW PRESCRIPTION REQUEST FORM in the editor.
2. Begin by entering the patient's name, date of birth, and member ID in the designated fields. This information is crucial for identifying the patient.
3. Next, fill in the doctor's name, DEA number, and NPI number. Ensure accuracy as this information is necessary for prescription authorization.
4. Provide the patient's address and contact details. This helps in maintaining clear communication regarding the prescription.
5. In the 'Notes/Allergies' section, include any relevant medical notes or allergies that may affect medication choices.
6. List each drug name and strength required along with quantity, directions for use, and desired refills. Be thorough to avoid any confusion.
7. Select your authorization preference for each medication by checking the appropriate box (e.g., 'I Authorize New Script plus 12 Refills').
8. Once completed, review all entries for accuracy before submitting. You can then fax it back or save it for further distribution.

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