Home Delivery Order Form - Magellan Rx Management
Magellan Rx Pharmacy
Home Delivery 90-Day Order Form
To be completed by a prescriber and faxed to 888-282-1349
1 Paent informaon. Please use black or blue ink.
Last Name
First Name
Delivery Address
MI
Gender
M
F
Apt. #
City
State
ZIP
Date of birth
/
/
2 Health history
Email
Phone
Medicaon Allergies:
Amoxil/Ampicillin Aspirin Cephalosporins Codeine
Erythromycin NSAIDs Penicillin Quinolones
None Known Sulfa Tetracyclines Others:
Health Condions:
Arthris Glaucoma Asthma Heart Condion Cancer High Blood Pressure Diabetes High Cholesterol
None Known Osteoporosis Thyroid Disease Others:
List all prescripon, over-the-counter and herbal medicaons taken regularly: (use addional sheet if necessary)
3 Prescripon informaon
Drug Name & Strength
Qty Direcons
DAW Refills
4 Prescriber informaon
Prescriber's Name Phone
Address
Prescriber Signature
DEA#
NPI#
Fax
Date
Magellan Rx - 6870 Shadowridge Drive, Suite 111, Orlando, FL 32812. Phone 800-424-8274 - Fax 888-282-1349 - NPI 1558738864 - DEA BI8515047
CONFIDENTIALITY NOTICE: The informaon contained in this communicaon is confidenal and intended for healthcare treatment. You are obligated to maintain it in a safe, secure and confidenal manner. Redisclosure of this informaon is prohibited except as other permied by applicable law or appropriate consent. If you are not the intended recipient of this message, or the employee or agent responsible for delivery to the intended recipient, you are hereby nofied that any disseminaon, distribuon or copying of this informaon is strictly prohibited. If you have received this message in error, please nofy the sender.
*** THIS FORM IS NOT VALID IN THE STATE OF ARIZONA ***
homedelivery
2023 Magellan Rx Management, LLC. All rights reserved. MRX1309_0423
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