Follow the steps to complete the Specialty Pharmacy Prescription Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in your selected application.
2. Begin by entering patient demographic information in the relevant fields. Provide the last name, first name, middle initial, address, city, state, zip code, phone number, alternate phone number, date of birth, and gender. Be sure to check for accuracy.
3. Move on to patient insurance information. If the patient has insurance, make sure to include copies of the front and back of their medical and prescription drug cards. If they opt for self-pay, select the appropriate choice for the payment duration (single, 4-month, or 24-month). Fill in the necessary details for both prescription and medical insurance, including phone numbers and subscriber numbers.
4. Input the policy holder information if it differs from the patient. Include the name, employer, and their relation to the patient.
5. Complete the prescriber information section with the prescriber’s name, office contact, address, title, and phone number. Indicate whether the prescriber has been trained in the placement of and include their license and NPI numbers.
6. If the shipping address is different from the patient’s, provide the new address in the designated section.
7. Fill out the prescription information with the medication name (e.g., ), appropriate ICD-9 diagnosis codes, and any necessary additional details regarding the prescription. Ensure the prescriber signs and dates the form to authorize the request.
8. In the optional patient charge card information section, record the credit or bank card details. This allows CVS Caremark to bill for any copays necessary without needing to contact the patient, up to the authorized amount selected.
9. Review the completed form for accuracy and completeness. Make any necessary adjustments before submission.
10. Finally, save changes to retain information, and then download, print, or share the completed form as needed.

Start filling out the Specialty Pharmacy Prescription Request Form - Caremark online today!