New Prescription Fax Form 86115 Return Within 48 Hours Not for CII prescriptions 90-day supply, when appropriate Have questions? Please call us at 1 888 327-9791 STEP 1 Complete all information below. Prescriber Information Prescriber Name: DEA No.: - Fax number: - (Only for CIII-CV prescriptions) NPI No.: Member Information Prescription Drug Card Member No.: (Include all characters. Leave box blank for spaces.) Member Name: (Card Holder) Patient Information Fill in or attach prescription below Patient Name DOB Prescriber Name Address City, State, Zip Tel. Ship to address Write or Stamp Here Patient Name: Allergies: None Sulfa Penicillin Aspirin Codeine NSAIDS Drug: Strength: Other Medical Conditions: Quantity: None STEP 2 DOB: Directions: Indicate the number of medications on this fax. Refills: _____ When applicable PRINT Supervising Physician name here Sign this prescription and fax to 1 800 837-0959 Fax from the prescriber's secure fax line. Do not fax with a cover sheet. Incomplete forms will cause a delay in processing. Sign and date here / / (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. 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 Express Scripts by fax or phone immediately. Express Scripts facsimile machines are secure and in compliance with HIPAA privacy standards. The provision of the information requested in this form is for your patient's benefit. Express Scripts does not compensate for completing this form.
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