US Script, PBM for Louisiana Healthcare Connections 2026

1. Click ‘Get Form’ to open the US Script, PBM for Louisiana Healthcare Connections form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, address, city, state, zip code, home phone number, alternate phone number, date of birth, and gender.
3. Next, complete the 'Other Shipping Location Information' if applicable. Provide the name and address of the shipping location along with contact details.
4. In the 'Prescriber Information' section, input the prescriber's name, specialty, NPI number, group or hospital affiliation, and their contact information.
5. Fill out the 'Insurance Information' by entering details for both primary and secondary insurance providers including ID numbers and phone numbers.
6. For the 'Statement of Medical Necessity', provide a diagnosis including ICD9 codes and any supporting clinical documentation. Indicate if this is a continuation of previous treatment.
7. Lastly, list the medication(s) requested along with strength/dose directions. Ensure to sign and date at the bottom before submitting.

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