Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the form and open it in your browser or PDF editor.
2. Begin by filling out the provider information section. Include the provider's name, National Provider Identifier (NPI), and the provider specialty.
3. Next, complete the patient information section. Add the patient’s name, date of birth, office contact person, Southern Scripts Patient ID, and the physician's address, including street, city, state, and zip code.
4. Provide information about the prescription, including the prescription number, pharmacy details, and patient phone number.
5. Indicate if the fax is secured and provide the Rx group number along with the diagnosis and date of diagnosis.
6. Fill out the medication requested section, specifying the medication name, strength, frequency, and quantity. Select whether it is a new or ongoing medication.
7. Answer whether the patient has shown improvement while undergoing therapy and check the applicable boxes in the conditions being treated section.
8. Provide information about the severity of the disease as mild, moderate, or severe, and indicate the anticipated length of therapy.
9. Address any previous failures, intolerance to treatments, or inadequate responses to conventional therapies, providing details as needed.
10. Include any other pertinent information to support the medical necessity of the medication. Additional documentation like progress notes may be attached.
11. Finally, ensure that the prescriber’s signature is included and add the date. After completing the form, you can save changes, download, print, or share the form via fax to (318) 214-4190.

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