Physician Fax Form 5 27 2008 Revised Fast Start
User Manual: Fax
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106-13946a
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 Prescription Information
DRUG NAME 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.
