Physician Fax Form 5 27 2008 Revised Fast Start
User Manual: Fax
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Fax # 1-800-378-0323 PRESCRIBER SERVICES New Prescription Request FastStart® Fax Form The following information is necessary in order to process your patient's prescription(s). Using this fax form will expedite the prescription for the patient. Please complete the 4 steps below. Step 1 Patient Information Patient Name: ______________________________________________________ DOB: _______________________ Address: __________________________________________________________ Phone: (_____) _______ - _______ City, ST, ZIP: ______________________________________________________ CVS Caremark ID #: _________________________________________________ Company: ___________________ Allergy Information: ________________________________________________ Step 2 DRUG NAME Prescription Information STRENGTH DIRECTIONS QUANTITY & REFILLS 1. _______________________________________________________________ 90 Days or ______, 1 Year or ______ 2. _______________________________________________________________ 90 Days or ______, 1 Year or ______ 3. _______________________________________________________________ 90 Days or ______, 1 Year or ______ 4. _______________________________________________________________ 90 Days or ______, 1 Year or ______ Prescriber Signature: __________________________________ Faxed By: ____________________________________________ Substitution Permissible – Unless Prescriber notes Brand Necessary or DAW on prescription Note: Schedule II Controlled Substances cannot be submitted via fax. Step 3 Physician Information Required Dr. Name: _________________________________________________________ Phone: (______) ______ - _______ Address: __________________________________________________________ Fax: (______) _________ - ______ City, ST, ZIP: ______________________________________________________ DEA #: ______________________ Step 4 Fax information toll-free to 1-800-378-0323 If you are not the intended recipient of this FAX, you are hereby notified that any disclosure, copying or distributing is prohibited. If you have received this FAX in error or if you would like to talk to our staff, please notify us by phone toll-free at 1-800-378-5697.Plan participant privacy is important to us. Our employees are trained regarding the appropriate way to handle our plan participants’ private health information. 106-13946a
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