Get Specialty Pharmacy Intake Form

This guide provides a comprehensive overview of the Specialty Pharmacy Intake Form, designed to assist users in completing the form online with ease. Follow the instructions carefully to ensure all necessary information is accurately submitted.

Follow the steps to complete your Specialty Pharmacy Intake Form online.

1. Press the ‘Get Form’ button to access the Specialty Pharmacy Intake Form and open it for editing.
2. Begin by filling out the Patient Information section. This includes entering the patient's name, street address, city, state, zip code, preferred phone number, email address, date of birth, and social security number if required.
3. In the Pharmacy Insurance Information section, provide details about the primary or secondary medical insurance. Attach copies of the insurance cards when indicated. Make sure to fill in the insurer's name, contact information, group number, policy number, and pharmacy insurance ID.
4. Complete the Prescriber Information by entering the office contact details, prescriber’s name, specialty, office name, address, and contact information. Ensure the prescriber NPI number is also provided.
5. Fill in the Prescription Information for ™. Include the prescribed dose, directions, quantity, and any refills requested. Make sure to sign the prescription where indicated.
6. Select a Specialty Pharmacy option from the list provided. Include the chosen pharmacy's contact information for further processing.
7. If applicable, complete the Patient Medical Information section, including providing primary and secondary ICD-10-CM codes if required.
8. Gather any necessary signatures from the prescriber and patient in the ™ Patient Start Program section, indicating consent to participate in the program.
9. After ensuring all required fields are completed, you may save changes to the form, download it, print it, or share it as needed.

Complete your Specialty Pharmacy Intake Form online today to facilitate timely processing of your request.