Get Prescription Form

Filling out the Prescription Form online is a straightforward process designed to ensure proper communication and care for patients. This guide provides step-by-step guidance to help users complete the form accurately and effectively.

Follow the steps to complete the Prescription Form successfully.

1. Press the ‘Get Form’ button to access the Prescription Form and open it in the designated editor.
2. Complete the patient and insurance information section by entering the first name, last name, middle initial, address, city, state, ZIP code, home phone number, cell phone number, work phone number, email, date of birth, and insurance details. Ensure to include copies of the front and back of the insurance cards.
3. Read and sign the voluntary patient authorizations section, which includes a statement for protected health information authorization and adherence support authorization. The patient or legal guardian should provide their signature and relationship to the patient, along with the date.
4. In the patient eligibility section, answer the questions regarding the patient's FDA-approved indication, gestational age, and whether they are currently receiving or compounded HPC.
5. Enter the prescriber information, including the prescriber’s name, NPI number, address, office phone number, and preferred method of communication.
6. Complete the prescription details, including dosage and refills. Specify the preferred injection setting and additional notes as necessary.
7. Fill out the optional Quick Start Program section, which includes details for initiating treatment within 5 business days if applicable.
8. Read and sign the prescriber authorization, certifying that the therapy is medically necessary and providing the prescriber's signature and date.
9. Once all sections are completed, save any changes, and download or print the form as needed. Ensure to fax the completed form along with the insurance cards to 1-800-847-3413.

Begin the process of filling out the Prescription Form online to ensure timely care for your patients.