Get Solutions Prescription And Service Request Form

Filling out the Solutions Prescription And Service Request Form is a crucial step in obtaining the medication ® (tasimelteon) through specialty pharmacies. This guide provides clear instructions on how to complete the form accurately for seamless processing.

Follow the steps to complete the Solutions Prescription And Service Request Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in an appropriate editor.
2. Begin by filling out the 'Patient Information' section. Include details such as the patient's first name, middle initial, last name, email, last four digits of their Social Security Number, address, state, city, zip code, and date of birth. Be sure to mark the preferred phone number and any options for leaving a message.
3. Complete the 'Insurance Information' section. Indicate whether the patient has insurance by selecting 'Yes' or 'No.' If applicable, provide details regarding the type of insurance (Medicare, Medicaid, or Other), including the prescription drug insurer, Bin number, ID number, group number, and contact phone.
4. In the 'Patient Signature' section, the patient must provide their signatures for both the Patient Services Authorization and Patient Marketing Authorization. Make sure to include the date next to each signature.
5. Fill out the 'Prescriber Information' section with the prescriber’s name, specialty, contact details, and various identification numbers to ensure proper identification and processing.
6. Complete the 'Prescription Information' section. Specify the prescription details for ® and include the necessary dispensing instructions.
7. Finally, review all the information provided to ensure it is complete and accurate. Once you are satisfied, proceed to save your changes, then download, print, or share the completed form as required.

Take the next step in managing your health by completing the Solutions Prescription And Service Request Form online today.