PRESCRIPTION VERIFICATION FORM 2026

1. Click ‘Get Form’ to open the PRESCRIPTION VERIFICATION FORM in our editor.
2. Begin by entering the Company Name and Company # at the top of the form. This identifies the organization associated with the prescription verification.
3. Fill in the Applicant Name and Employee Social Security Number. Ensure accuracy as this information is crucial for verification purposes.
4. Indicate the drug for which the person tested positive, using specific identifiers like NC-2 or NC-6.
5. Answer whether the name on the prescription matches the applicant's name by selecting 'Yes' or 'No'.
6. Specify how many prescriptions are being sent for review by circling a number from 1 to 7, or writing 'Other' if applicable.
7. For each prescription (up to three), provide details including Name of drug, Date issued, and Directions/instructions.
8. The designated representative should print their name and sign at the bottom of the form, certifying that all information is accurate.
9. Finally, ensure that both the applicant/employee signs and dates the form before submission.

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