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Prescriber Vendor Release Form Fax Completed Form to 703 - cphealthnet

Prescriber Vendor Release Form Fax Completed Form to 703 - cphealthnet 2025

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The document is a Prescriber Vendor Release Form used for switching e-Prescribing vendors or adding a new refill capable location with a new vendor. It requires prescriber information, new vendor details, and authorization. All fields marked with an asterisk are mandatory, and incomplete forms will not be processed. The form must be faxed to Surescripts support for processing.

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