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

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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