magellan rx pharmacy specialty order form · 2020-06-05 · magellan rx pharmacy complete...
TRANSCRIPT
Pa�ent Informa�on Clinical Informa�on
Last name First name MI
Street Address Apt. #
City State ZIP
Date of birth Gender
English Other, please specify _________________
Parent/Guardian/Emergency contact
Home phone
Cell phone
Email address
Pa�ent’s primary language
Work phone
Phone Rela�onship
Pa�ent Insurance Informa�on
Prescrip�on Informa�on
Prescriber Informa�on
Insurance company Phone
Insured’s employer
Rela�onship to pa�ent
Insured’s name
Medica�on Strength/Form Direc�ons Quan�ty/Refills
I consent to Magellan Rx auto-enrolling me in available pa�ent assistance program(s)
Iden�fica�on #
Policy #
Is pa�ent eligible for Medicare?
BIN #
Group # PCN #
Y N
Yes No Office Pa�ent’s home Clinic
MD DO NP PA
Prescriber’s name Date
Title (please check one)
Office contact
Street address
City
Suite #
State
Phone Fax
NPI # License #
DEA # XDEA #
Deliver product to:
Shipping address (if different than above)
ZIP
M F
NKDA Known drug or food allergies __________________________________________
Other Diagnosis code
Height Weight
Specialty Order Form
magellanrx.com2020 Magellan Rx Management, LLC. All rights reserved. MRX1039_0220
Please fax completed form to 866-364-2673. For ques�ons about MRx Specialty Pharmacy, contact us at 866-554-2673.The document(s) accompanying this transmission may contain confiden�al health informa�on that is legally privileged. This informa�on is intended only for the use of the individual or en�ty named above. The authorized recipient of this informa�on is prohibited from disclosing this informa�on to any other party unless required to do so by law or regula�on. If you are not the intended recipient, you are hereby no�fied that any disclosure, copying, distribu�on or ac�on taken in reliance on the contents of these documents is strictly prohibited. If you have received this informa�on in error, please no�fy the sender immediately and arrange for the return or destruc�on of these documents.
Magellan Rx Pharmacy
Complete information below OR copy and attach both the front and back of the patient’s prescription insurance card(s)
List supplies, any other prescrip�on, over-the-counter, and herbal medica�onstaken regularly:
If Nurse Prac��oner or Physician Assistant, physician agreement under direc�on of Dr.
By signing below, I cer�fy that the above therapy is medically necessary.
__________________________________________________________________Prescriber’s signature (Physician a�ests this is their legal signature. NO STAMPS.)
Date Subs�tu�on allowed Date Dispense as wri�en
Prescriber, please check here to authorize ancillary supplies such as needles, syringes, sterile water, etc. to administer the therapy.
Sufficient quan�ty for medica�on dosage.
As needed for administra�on.
Dispense: 1-month supply 3-month supply Other _______________Refills __________
The prescriber is to comply with their state-specific prescrip�on requirements such as e-prescribing, state-specific prescrip�on form, fax, etc. Non-compliance with state-specific requirements could result in outreach to the prescriber.
Primary ICD-10 code