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Referral/Prescription Form To ensure enrollment please fax to the Care Connection 1-800-847-3413 Telephone 1-800-847-3418 www. .com STEP 1 Complete Patient and Insurance Information Required please include copies of front and back of insurance cards First Name Last Name MI Prescription Drug Insurer/Pharmacy Benefit Manager City State ZIP Home Phone Work Phone Best Time to Contact BIN ID Address Cell Phone Clear Field Phone Group Primary Medical Insurance Cardholder Name Date of Birth Policy ID Number Email Primary Language if Not English Relationship to Cardholder Secondary Medical Insurance Known Allergies Patient does not have insurance Does patient have prescription drug card Yes No STEP 2 Read and Sign Patient Authorization Optional however signature is required for financial assistance By signing this Authorization I authorize my health plans physicians and pharmacy providers to disclose my personal health information including but not limited to information relating to my medical....

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A prescription comprises various parts, such as the superscription or heading with the symbol "R" or "Rx", which stands for the word recipe (meaning, in Latin, to take); the inscription, which contains the names and quantities of the ingredients; the subscription or directions for compounding the drug; and the ...

Parts of Prescription Prescriber office information. Date. Patient data (Name, Age, Sex, and Address of the Patient) Superscription (Symbol ℞) Inscription (Medication prescribed)- Main part of a prescription. Subscription (Direction to Pharmacist/ Dispenser) Signatura or Transcription (Direction for Patient)

Definition/Introduction Date of issue. Patient's name and address. Patient's date of birth. Clinician name, address, DEA number. Drug name. Drug strength. Dosage form. Quantity prescribed.

Parts of Prescription Prescriber office information. Date. Patient data (Name, Age, Sex, and Address of the Patient) Superscription (Symbol ℞) Inscription (Medication prescribed)- Main part of a prescription. Subscription (Direction to Pharmacist/ Dispenser) Signatura or Transcription (Direction for Patient)

Definition/Introduction Date of issue. Patient's name and address. Patient's date of birth. Clinician name, address, DEA number. Drug name. Drug strength. Dosage form. Quantity prescribed.

A prescription is an order that is written by you, the physician (or future physician), to tell the pharmacist what medication you want your patient to take.

The following information must be on every prescription label: Name and address of the dispensing pharmacy. Serial number of the prescription. Date of the prescription. Name of the prescriber. Name of the patient. Name and strength of the drug.

Predating modern legal definitions of a prescription, a prescription traditionally is composed of four parts: a superscription, inscription, subscription, and signature. The superscription section contains the date of the prescription and patient information (name, address, age, etc.).

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232