New Prescription Fax Form

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.