Specialty Pharmacy Form - Blue Cross and Blue Shield of Alabama - bcbsal 2026

1. Click ‘Get Form’ to open the Specialty Pharmacy Form in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's Group Number, Contract Number, First Name, Last Name, and Middle Initial. Ensure you include the Social Security Number and Date of Birth.
3. Provide contact details such as Address, City, State, County, Zip Code, Day Telephone, Night Telephone, E-mail, and indicate any Allergies along with Patient Weight.
4. Next, complete the Physician Information section. Fill in the PMD Prescriber’s Name, Office Contact details including Address and Telephone number. Include the Prescriber’s License Number and DEA Number if applicable.
5. In the Prescription Information section, specify the Drug Name, Dose, Quantity/Day Supply, SIG/Directions for use, and Refills. You may also note any Ancillary Supplies needed.
6. Finally, review all entries for accuracy before signing at the bottom of the form. Ensure that you provide your Title and Date next to your signature.

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