Get Drug Request Form

Completing the Drug Request Form online can streamline the process of obtaining necessary medications. This guide will provide step-by-step instructions to help you navigate each section of the form confidently.

Follow the steps to complete the Drug Request Form.

1. Press the ‘Get Form’ button to access the Drug Request Form and open it in your preferred online editor.
2. Begin by filling out the prescription information section. This includes providing your subscriber ID number, group number, patient name, phone number, address, date of birth, and zip code. Ensure this information is correct and complete.
3. Next, specify the drug name, strength, quantity, directions, and number of refills requested. Indicate the date the prescription is needed and choose the shipping option — either to the physician’s office or the patient’s home.
4. The physician's signature is required in this section, along with their DEA number and diagnosis. If alternatives have been tried or used by the patient, make sure to provide the drug names and strengths, along with documentation of any therapy failures.
5. Explain the medical rationale for the proposed drug therapy or treatment plan in the designated space. This helps clarify the need for the requested medication.
6. Fill in the physician information section with the physician’s name, phone number, address, and fax number, ensuring that all details are legible for future communications.
7. After reviewing all filled sections for accuracy, save your changes, then either download, print, or share the form as needed.
8. Finally, fax the completed form to 1-866-240-8123 or mail it to the Medical & Pharmacy Affairs at the specified address.

Start completing your Drug Request Form online today!