Get Surescripts Prescriber Vendor Release Form

The Surescripts Prescriber Vendor Release Form is essential for prescribers who are switching vendors or adding a new refill-capable location. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, enter the prescriber information. This includes the prescriber’s first and last name, practice or clinic name, practice address (note that a PO Box is not acceptable), phone number, fax number (ensure this can receive refill requests), NPI number, and DEA number. If available, provide both NPI and DEA numbers.
3. In Section II, input the name of the new vendor. Remember that Surescripts is not a vendor. Select the e-prescribing services you will use, such as NewRx, Med History, Refill, or Eligibility.
4. Indicate the effective date for the changes in the format of month/day. Ensure that a date is provided to avoid processing issues.
5. The authorized representative must sign and print their name in the designated space. This certifies that they are authorized to make changes on behalf of the prescribing physician.
6. Review all entries carefully to ensure completeness, as all fields marked with an asterisk are required. Incomplete forms will not be processed.
7. Once completed, save the changes, then download, print, or share the form as necessary. If you have questions, contact Surescripts Support at 1-866-RxReady (866-797-3239).

Complete your Surescripts Prescriber Vendor Release Form online today to ensure a smooth transition!