Transcription of New Prescription Fax Form - myjcbenefits.com
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New Prescription Fax Form - myjcbenefits.com
AspirinCodeineNSAIDS(Only for CIII-CV prescriptions) NPI No.:Patient In formationShip to addressPatient questions? Please call us atPrescriber In formation Not for CII prescriptions 90-day supply, when appropriateAllergies:Medical Conditions:NoneComplete all information 1 Return WithinSTEP 2 Hours Fax fromthe prescriber's securefax line. Do notfax with a cover sheet. Incomplete forms will cause a delay in the number of medications on this this prescriptionand fax toPrescriberName:DEA No.:Fax number:New Prescription Fax FormPrescription DrugCard Member No.:Member Name:(Card Holder)Member In formationOt herNoneSulfaPenicillin(Include all characters. Leave box blank for spaces.)- -1 888 327-97911 800 837-09598611548 Confidentialit y Notice:This communication andanyattachments areintendedsolely for the use of the addressee named above andcontains confidential andlegally pri vileged information.
Aspirin Codeine NSAIDS (Only for CIII-CV prescriptions) NPI No.: Patient Information Ship to address Patient Name DOB Tel. Have questions? Please call us at
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