Get Current Prescription Form

Filling out the Current Prescription Form online is a straightforward process that ensures accurate and timely submission of prescription information. This guide will walk you through each step of navigating the form, making it accessible for all users.

Follow the steps to complete the Current Prescription Form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the digital editor.
2. Begin by entering the patient information. Fill in the patient’s name, date of birth, gender, and the last four digits of their social security number. Provide the patient’s full address, including street, apartment number (if applicable), city, state, and zip code.
3. Next, if applicable, fill out the parent or guardian's details and select the principal contact. Include contact numbers for the home and work, as well as cell and evening phone numbers.
4. Provide the patient’s email address and insurance information. Enter the insurance company name and contact number. Complete the insured’s name and the last four digits of their social security number.
5. Indicate the relationship of the insured to the patient and fill in the identification and policy/group numbers. If there is a secondary insurance, repeat the process for that insurance provider as well.
6. In the prescriber information section, enter the date, prescriber’s name and title, and their address. Be sure to include the license number and DEA/NPI number.
7. Complete the clinical information by stating the primary diagnosis, ICD-9/ICD-10 code, current weight, medical history, and any special instructions.
8. In the prescribing information section, indicate the chosen product and the quantity. Confirm that it is to be administered by a physician and note any required prior authorizations.

Complete the Current Prescription Form online successfully to ensure your prescription needs are met promptly.