YOUR PATIENT WOULD LIKE TO RECEIVE THEIR PRESCRIPTION MEDICATION BY MAIL.
34202 Please complete ALL information below.
Note to Prescriber
Questions? Call 1.888.327.9791
Required for CIII-CV medications
Secure fax number
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(Include all characters.Leave box blank for spaces )
Member Name(card holder):
Patient Name DOB Ship to address
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Fax forms wil only be accepted when sent from a prescriber's office. The printed fax confirmation is proof of receipt. Most patients can receive a 90-day supply plus refills up to 1 year (as appropriate).
Prescriber Signature Substitution Permissible Prescriber Signature Dispense as Written
(We cannot accept Signature Stamps)
Confidentiality Notice:This communication and any attachments are intended solely for the use of the addressee named above, and it contains confidential and legally privileged information. If you are not the intended recipient, any dissemination, distribution, or copying is strictly prohibited. If you received this communication in error, please notify Express Scripts by fax or phone immediately.The Express Scripts fax system is secure and in compliance with HIPAA privacy standards.
This page was last updated on 06/15/2013. © 2013 Express Scripts Holding Company. All Rights Reserved.