Transcription of ~. ORDER FORM FROM EXPRESSSCRIPTS Fax to: …
1 " 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.
2 Ta;i"'lthis nformoliooIn ony ctl\erpartyunlessrequredto do so by tNlC< '1<:<1"'"net It\eintendedrecipient,youare Ilerebynotfiedthatony dsclosure,<DP'ling,distributioo,Ofadi<:ntakenin relanceO'! the rontel1tsof thesedCOJmenrs~ stri< you havereceived!!lis i"lfomlatJonnerror,pleasenotifythe senderilllllediatelyand "rr""gefur the retu",or de>trueticnof thesedocurrerts. 2007 EXPRESSSCRIPTS .
