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Get Order Form from Express Scripts 2007-2024

CII prescriptions CANNOT be faxed. For future orders you must use this form to fax orders to Express Scripts. - EXPRESS SCRIPTS. ORDER FORM FROM EXPRESS SCRIPTS Fax to 800-396-2171 It can take up to 72 hours for the prescription to be entered into our system after your fax is received. It is not necessary to resend the prescription or to call the prescription into our Service Center. Doing so will only delay the fulfillment of your patient s order. Only a prescriber s office may submit fax prescriptions. 1. Fill in ALL of the information below. Dr/Prescriber Name 1 1I w m Q u Ul DEAor NPI Address City State Zip Phone Fax c Mid-Level Practitioner s Supervising Physidan Name Patient Name z 1-4 Plan 10 ce l- Date of Birth Rx Form Date ONE Fax Form per Patient In order for a brand name product to be dispensed the prescriber MUST handwrite BRAND NECESSARY or BRAND MEDICALLY NECESSARY in the table below. Strength DrugNcme Qly Directions For Use RefiDs Brand Necessary I Brand Medically Necessary Printed Name Signature - SUbstitution Permissible X l pa1ant Confidentially I ti e This and any docurrents ao anpanyilg this t nsmissbn may coolain rooMential health irfumatbn that Jilly pr*viege J* Th ilfonnation is nlffid d 0 1y fo- tlle US d tl e iroi ld l elf entily named beNe The ilUtlni2ed re ipient d this infonmlim is prohibited from disf. ta i l this nformolioo In ony ctl er party unless requred to do so by tNl C region* If 1 1 net It e intended recipient you are Ilereby notfied that ony dsclosure DP ling distributioo Of adi n taken in relance O the rontel1ts of these dCOJmenrs stri lly pro/libited* If you have received lis i lfomlatJon n error please notify the sender illllled iately and rr ge fur the retu or de trueticn of these docurrerts. 1. Fill in ALL of the information below. Dr/Prescriber Name 1 1I w m Q u Ul DEAor NPI Address City State Zip Phone Fax c Mid-Level Practitioner s Supervising Physidan Name Patient Name z 1-4 Plan 10 ce l- Date of Birth Rx Form Date ONE Fax Form per Patient In order for a brand name product to be dispensed the prescriber MUST handwrite BRAND NECESSARY or BRAND MEDICALLY NECESSARY in the table below. Strength DrugNcme Qly Directions For Use RefiDs Brand Necessary I Brand Medically Necessary Printed Name Signature - SUbstitution Permissible X l pa1ant Confidentially I ti e This and any docurrents ao anpanyilg this t nsmissbn may coolain rooMential health irfumatbn that Jilly pr*viege J* Th ilfonnation is nlffid d 0 1y fo- tlle US d tl e iroi ld l elf entily named beNe The ilUtlni2ed re ipient d this infonmlim is prohibited from disf. Strength DrugNcme Qly Directions For Use RefiDs Brand Necessary I Brand Medically Necessary Printed Name Signature - SUbstitution Permissible X l pa1ant Confidentially I ti e This and any docurrents ao anpanyilg this t nsmissbn may coolain rooMential health irfumatbn that Jilly pr*viege J* Th ilfonnation is nlffid d 0 1y fo- tlle US d tl e iroi ld l elf entily named beNe The ilUtlni2ed re ipient d this infonmlim is prohibited from disf. ta i l this nformolioo In ony ctl er party unless requred to do so by tNl C region* If 1 1 net It e intended recipient you are Ilereby notfied that ony dsclosure DP ling distributioo Of adi n taken in relance O the rontel1ts of these dCOJmenrs stri lly pro/libited* If you have received lis i lfomlatJon n error please notify the sender illllled iately and rr ge fur the retu or de trueticn of these docurrerts. .

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