Loading
Get 18007917658
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the 18007917658 online
Filling out the 18007917658 form online can seem daunting, but this guide aims to simplify the process. By following the step-by-step instructions, you will be equipped to complete the form efficiently and accurately.
Follow the steps to successfully complete the 18007917658 form.
- Click 'Get Form' button to obtain the form and open it in the editor.
- Begin by entering the patient's information, including their full name, date of birth, and sex. Ensure that all details are accurate and carefully checked.
- Provide the patient's insurance ID number and shipping address. Include the city, state, zip code, and phone number to ensure proper delivery of services.
- Next, indicate any known drug allergies by selecting from the provided options. If there are no known allergies, choose 'None Known.'
- List any health conditions the patient currently has by selecting from the given options, such as diabetes or asthma. If additional conditions apply, ensure to detail them accordingly.
- For each medication prescribed, fill out the medication name and strength. Provide clear directions for use, and specify the quantity and desired refills.
- Complete the physician's information section by entering their name, NPI, DEA, address, and contact information. Ensure all fields are filled out accurately.
- Sign and date the form in the designated area to confirm the information provided is correct and complete.
- After completed, save your changes, and choose to download or print the form. Finally, fax the completed form back to the provided number: 1-800-491-7997.
Ready to complete your documents online? Get started now!
The three biggest PBMs — CVS Caremark, Express Scripts and OptumRx — control nearly 80% of the prescription drug market, and are owned by CVS (which owns payer Aetna), Cigna and UnitedHealth (which operates payer UnitedHealthcare), respectively.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.