Prescription and Service Request Form 2026

1. Click ‘Get Form’ to open the Prescription and Service Request Form in the editor.
2. Begin by completing the Physician Information section. Fill in the Prescriber’s Name, Office/Clinic/Institution, and contact details including phone numbers.
3. Next, move to the Patient Information section. Enter the Patient's Name, SS#, DOB, and address. Ensure you select a preferred phone contact method.
4. In Step 2A, obtain Patient Authorization by having the patient sign and date where indicated. This confirms their understanding of information disclosure.
5. Proceed to Step 3 to check any applicable boxes for Start-up Rx and Titration Orders. Specify delivery methods and any necessary instructions.
6. Complete insurance details in Step 4, providing information about primary insurance and attaching relevant cards if needed.
7. Finally, in Step 5, complete and sign the Statement of Medical Necessity with accurate diagnosis codes before submitting your form.

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