Magellan Rx Pharmacy Specialty Order Form
Magellan Rx Pharmacy
Specialty Order Form
Paent Informaon
Last name Date of birth Street Address
First name
MI
Gender M F
Apt. #
Clinical Informaon
Primary ICD-10 code Other Diagnosis code
NKDA Known drug or food allergies __________________________________________
City Home phone Cell phone
State
ZIP
Work phone
Height
Weight
List supplies, any other prescrip on, over-the-counter, and herbal medica ons taken regularly:
Email address
Parent/Guardian/Emergency contact
Phone
Rela onship
Pa ent's primary language English Other, please specify _________________
Paent Insurance Informaon
Complete informaon below OR copy and aach both the front and back of the paent's prescripon insurance card(s)
Insurance company
Phone
Insured's name
Prescriber Informaon
Prescriber's name
Date
Title (please check one) MD DO NP PA
If Nurse Prac oner or Physician Assistant, physician agreement under direc on of Dr.
Office contact Street address City
Suite #
State
ZIP
Insured's employer Rela onship to pa ent Iden fica on #
BIN #
Phone NPI # DEA #
Fax License # XDEA #
Policy #
Group #
PCN #
Is pa ent eligible for Medicare? Yes No
I consent to Magellan Rx auto-enrolling me in available pa ent assistance program(s) Y N
Deliver product to:
Shipping address (if different than above) Office Pa ent's home Clinic
Prescripon Informaon
Medicaon
Strength/Form
Direcons
Quanty/Refills
Dispense: 1-month supply 3-month supply Other _______________ Refills __________
Prescriber, please check here to authorize ancillary supplies such as needles, syringes, sterile water, etc. to administer the therapy.
As needed for administra on.
Sufficient quan ty for medica on dosage.
The prescriber is to comply with their state-specific prescripon requirements such as e-prescribing, state-specific prescripon form, fax, etc. Non-compliance with state-specific requirements could result in outreach to the prescriber.
By signing below, I cer fy that the above therapy is medically necessary.
__________________________________________________________________ Prescriber's signature (Physician a ests this is their legal signature. NO STAMPS.)
Date
Subs tu on allowed
Date
Dispense as wri en
Please fax completed form to 866-364-2673. For quesons about Magellan Rx Pharmacy, contact us at 866-554-2673.
CONFIDENTIALITY NOTICE: The informa on contained in this communica on is confiden al and intended for healthcare treatment. You are obligated to maintain it in a safe, secure and confiden al manner. Redisclosure of this informa on is prohibited except as other permi ed 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 no fied that any dissemina on, distribu on or copying of this informa on is strictly prohibited. If you have received this message in error, please no fy the sender.
*** THIS FORM IS NOT VALID IN THE STATE OF ARIZONA ***
specialtypharmacy 2023 Magellan Rx Management, LLC. All rights reserved. MRX1039_0423
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