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Prescriber Vendor Release Form Fax Completed Form to 703 - cphealthnet

Prescriber Vendor Release Form Fax Completed Form to 703 - cphealthnet 2026

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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, including name, practice details, and necessary identification numbers, as well as new vendor information. All required fields must be completed for processing, and the form should be faxed to Surescripts support. The document emphasizes the importance of providing accurate information and includes instructions for completion.

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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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Prescriber Vendor Release Form Fax Completed Form to 703 - cphealthnet 2026

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How do I sign my Prescriber Vendor Release Form Fax Completed Form to 703 - cphealthnet on iOS?

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