Get Enrollment Form Directions For Patients -

Filling out the Enrollment Form Directions for Patients is an essential step in processing your prescription through Direct Success Pharmacy. This guide will provide you with clear and supportive instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your enrollment form.

1. Click the ‘Get Form’ button to obtain the Enrollment Form and open it in your preferred online document editor.
2. Complete the prescriber information section. Your physician must fill out the prescriber’s name, state license number, NPI number, DEA number, contact name, phone number, fax number, address, city, state, zip code, and primary specialty.
3. In the Rx information and physician authorization section, provide the necessary dosing instructions for XL. Select the appropriate dosage and supply duration, and ensure the prescriber initials the section for no substitution.
4. Next, move to the patient information section. Fill in your first and last name, preferred phone number, date of birth, and indicate your preferred time for a call. Remember to note if it is not okay to leave a message.
5. After filling out all the required information, ensure that your prescriber has signed the form, as they are required to do so — no signature stamps will be accepted.
6. Once completed, retain Page Two and Page Three for your records and proceed to submit the form. You may submit it via ePrescription by selecting Direct Success Pharmacy, fax it to 866-468-8274, or mail it to the provided address.
7. If you encounter any issues while filling out or submitting the form, contact Direct Success Pharmacy for support at 800-520-3185.

Complete your Enrollment Form online today and take the first step towards processing your prescription!