Fertility Prescription Referral Form - Avella Specialty Pharmacy 2025

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The document outlines the procedures for faxing prescriptions, emphasizing that only original prescriptions from prescribing practitioners are accepted. It includes a Fertility Prescription Referral Form with sections for prescriber and patient information, medication details, and insurance requirements. Additionally, it provides contact information for distribution centers and highlights the importance of confidentiality in handling the faxed information.

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Click ‘Get Form’ to open the Fertility Prescription Referral Form in the editor.
Begin by filling out the Prescriber Information section. Enter the Provider Name, DEA#, Address, Phone, Fax, Key Contact, City, State, Zip, NPI#, and Tax ID#. Ensure all details are accurate for seamless processing.
Next, complete the Patient Information section. Input the Patient Name, Birthdate, Social Security Number, Sex (Male/Female), Preferred Phone number, Address, City, and Alternate Caregiver Name. This information is crucial for identifying the patient.
In the Diagnosis/Clinical Information section, check appropriate boxes for treatments like IVF or IUI and provide height and known allergies. Include any recent clinical notes or lab tests by faxing them along with the prescription.
Fill out the Prescription Information section meticulously. Specify medication names, quantities (Qty), dosage instructions (Sig.), and refills as needed. Double-check each entry to avoid errors.
Finally, sign and date in the Patient Support Programs area to enroll in any assistance programs offered by pharmaceutical companies.

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