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Get Catamaran Form 86125 New Prescription Form

Cardholder name STEP 1 Complete all information below. Prescriber Information NPI Prescriber Name DEA Fax STEP 2 Not for CII prescriptions Fill in or attach prescription below Telephone NPI required for all prescriptions DEA required for CIII-CV prescriptions - Patient Information Date of birth Address City State Zip Ship to address Write or stamp here Fill out one form for each Rx STEP 3 Patient Name Indicate number of medications on this page. Drug Strength Quantity Have questions Call 1 866 834-0449. Directions For reporting allergies or medical conditions press option 5 Monday-Friday 9 00 am - 8 00 pm Eastern. Refills up to 3 refills X STEP 4 Sign this prescription and fax to Date / Stamps are not accepted. Signature required. In order for a brand name product to be dispensed the prescriber must handwrite brand necessary or brand medically necessary in the space below. 1 866 996-4921 Fax from the prescriber s secure fax line. Do not fax with a cover sheet. Incomplete forms will cause a delay in processing. When applicable PRINT Supervising Physician name here Confidentiality Notice This communication and any attachments are intended solely for the use of the addressee named above and contains confidential and legally privileged information. If you are not the intended recipient any dissemination distribution or copying is strictly prohibited. If you received this communication in error please notify Catamaran Home Delivery by fax or phone immediately. NEW PRESCRIPTION FAX FORM 86125 Member Information Cardholder ID Include all characters. Leave box blank for spaces. Cardholder name STEP 1 Complete all information below. Prescriber Information NPI Prescriber Name DEA Fax STEP 2 Not for CII prescriptions Fill in or attach prescription below Telephone NPI required for all prescriptions DEA required for CIII-CV prescriptions - Patient Information Date of birth Address City State Zip Ship to address Write or stamp here Fill out one form for each Rx STEP 3 Patient Name Indicate number of medications on this page. Drug Strength Quantity Have questions Call 1 866 834-0449. Directions For reporting allergies or medical conditions press option 5 Monday-Friday 9 00 am - 8 00 pm Eastern* Refills up to 3 refills X STEP 4 Sign this prescription and fax to Date / Stamps are not accepted* Signature required* In order for a brand name product to be dispensed the prescriber must handwrite brand necessary or brand medically necessary in the space below. 1 866 996-4921 Fax from the prescriber s secure fax line. Do not fax with a cover sheet. Incomplete forms will cause a delay in processing* When applicable PRINT Supervising Physician name here Confidentiality Notice This communication and any attachments are intended solely for the use of the addressee named above and contains confidential and legally privileged information* If you are not the intended recipient any dissemination distribution or copying is strictly prohibited* If you received this communication in error please notify Catamaran Home Delivery by fax or phone immediately. .

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