New Prescription Fax Form - Express Scripts
[Pages:1]New Prescription Fax Form
86115
Not for CII prescriptions 90-day supply, when appropriate
Have questions? Please call us at 1 888 327-9791
48 Return Within Hours
STEP 1 Complete all information below.
Prescriber Information
Prescriber Name:
DEA No.: (Only for CIII-CV prescriptions)
Fax number:
-
-
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
Tel.
Prescriber Name Address
City, State, Zip
Ship to address
Allergies: None
Aspirin
Other Medical Conditions:
None
Sulfa Codeine
Penicillin NSAIDS
Patient Name: DOB:
Drug: Strength: Quantity: Directions:
Write or Stamp Here
STEP 2 Indicate the number of
medications on this fax.
Refills: _____
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.
When applicable PRINT Supervising Physician name here
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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