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How to use or fill out Prescriber Vendor Release Form Fax Completed Form to 703 - cphealthnet
- Click ‘Get Form’ to open it in the editor.
- Begin with Section I: Prescriber Information. Fill in your first and last name, practice/clinic name, address (no PO Box), phone number, fax number, NPI number, DEA number, and Surescripts case number. Ensure all fields marked with an asterisk (*) are completed.
- Proceed to Section II: New Vendor Information. Enter the name of your new e-Prescribing vendor (note that Surescripts is not a vendor). Select the e-Prescribing services you require and specify the effective date for the changes.
- In the Authorized By section, sign and print your name to certify that you are authorized by the prescribing physician to make these changes.
- Review all entries for accuracy before submitting. Incomplete forms will not be processed.
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