Transcription of ~. ORDER FORM FROM EXPRESSSCRIPTS Fax to: …
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Example: stock market
~. ORDER FORM FROM EXPRESSSCRIPTS Fax to: …
" EXPRESSSCRIPTS '~.ORDERFORMFROMEXPRESSSC RIPTSFax to: 800-396-2171It cantakeupto72hoursfortheprescriptiontobe enteredintooursystemafteryourfaxis ' ' :1:1I::wmDEAorNPI #:Address,City,State,Zip:Q!uPhone:Ulw1:1 I:: :1I::Mid-LevelPractitioner'sSupervisingP hysidanName:cPatientName: zwPlan10:Address,City,State,Zip:1-4l- :RxForm(ONEFaxFormperPatient)Date:Inorde rfora brandnameproducttobedispensed,theprescri berMUST handwrite'BRANDNECESSARY'or'BRANDMEDICAL LYNECESSARY'in BrandMedicallyNecessary123Dr/PrescriberP rintedNameDr/PrescriberSignature- SUbstitutionPermissibleXl",pa1antConfide ntiallyI :ti::e;Thisand any docurrentsao:anpanyilgthis t",nsmissbnmaycoolainrooMentialhealthirf umatbnthat~ "' < ~ilfonnationis nlffid d0'!1yfo- tlle US<'d tl;eiroi\ld""lelf entilynamed"beNeThe ilUtlni2edre::ipientdthis infonmlimis prohibitedfromdisf.
-"EXPRESS SCRIPTS' ~. ORDER FORM FROM EXPRESSSCRIPTS Fax to:800-396-2171 It can take up to 72 hours for the prescriptionto be …
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