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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