Get Order Form

This guide provides clear and comprehensive instructions on how to fill out the Order Form online. Follow the steps below to ensure a smooth and efficient submission process.

Follow the steps to complete your Order Form submission

1. Click ‘Get Form’ button to access the Order Form and open it in your preferred online editor that allows for editing and submission.
2. Select your choice of specialty pharmacies by checking the appropriate boxes for either Accredo or CVS Caremark to facilitate the prescription fulfillment process.
3. Fill in the patient information section. Make sure to complete all required fields, including phone numbers and whether the patient is a new patient.
4. Input the clinical information. Provide the primary ICD-10 code and any other relevant medical information, including known drug allergies and concurrent medications.
5. Complete the prescriber information section. Make sure to enter the prescriber’s name, title, contact information, and clinic/hospital affiliation accurately.
6. In the prescription information section, include the patient's personal details, prescription specifics, and confirm their consent regarding health information use.
7. Attach a copy of the patient's insurance card or provide the required insurance information in the designated fields.
8. Make sure to sign the required authorization section to permit the use and release of protected health information, ensuring you understand the terms stated.
9. Once all fields are completed, proceed to save changes. You can download, print, or share the form as needed for submission.

Complete your Order Form online with confidence and ensure all information is accurate for a seamless submission.