Transcription of New Prescription Fax Form - Express Scripts
1 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.
2 :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. If you are not the intended recipient, any dissemination, distribution or copying is strictly prohibited. If you received thiscommunication in error, please notify Express Scripts by fax or phone immediately.
3 Express Scripts facsimile machines are secure and in compliance with HIPAA privacy provision of the information requested in this form is for your patient's benefit. Express Scripts does not compensate for completing this or Stamp HereRefills:Prescriber NameAddressCity, State, ZipFill in or attach Prescription belowWhen applicable PRINT Superv ising Physician name here / /In order for a brand name product to be dispensed, the prescriber must handwrite"brandnecessary" or "brandmedicallynecessary" in the space and date here (Stamps are not accepted.)
4 Signature re quire d.) Drug: Strength: Quantity: Directions:Patient Name: DOB:_____
