Get Express Scripts Physician Mail Order Form - Www2 Illinois

The Express Scripts Physician Mail Order Form allows healthcare providers to request prescriptions to be mailed to their patients. This guide offers clear, step-by-step instructions for completing the form online, ensuring a seamless experience for both prescribers and patients.

Follow the steps to complete the Express Scripts Physician Mail Order Form.

1. Click ‘Get Form’ button to obtain the form and open it in the designated platform.
2. Fill in the prescriber information, including your name, DEA number (if applicable), secure fax number, and NPI. Ensure that all required fields are completed.
3. Enter the member information by inputting the member number and the name of the cardholder in the appropriate fields.
4. Provide patient information, which includes the patient's name, date of birth, and telephone number. Enter the shipping address where the prescription should be sent. Document any known allergies and medical conditions from the provided options.
5. In the prescription information section, attach or specify the prescription details clearly. Include the issue date and refills if necessary. Obtain the prescriber’s signature, ensuring it is handwritten, as signature stamps are not accepted.
6. For submitting the form, note that this page should be faxed to 1 800 837-0959 without a cover sheet. Remember, CII prescriptions cannot be accepted via fax. The printed fax confirmation will serve as proof of receipt.

Complete your documents online today for an efficient and streamlined process.