Patient Insurance Information Form

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FAX ORDER FORM TO:
877-283-9171
For: ________________________________
Date ____________
To the Physician: Please fax this form to Eagle Pharmacy to help facilitate this
Address: ____________________________ Phone _____________
patient’s prescription order.
RX
To the patient: 1) Fully complete the Patient and Insurance Information
requested below. 2) Have your doctor supply the prescription information
requested using the Rx form on the left. 3) Ask your doctor to fax this form to
the fax number shown above. 4) Make certain a valid credit card is on file with
Eagle Pharmacy to ensure your order may be processed without delay.
PATIENT INFORMATION
Patient Last Name
Patient First Name
Gender
Birth Date
Dr: _________________________
Dr. _____________________
Dispense as Written
Substitution Allowed
List Allergies:
None
Physician Name (Please Print) ______________________________
1.
2.
3.
Physician Last Name
Physician First Name
Physician Telephone
Refill _______
Address __________________________________
DEA# ________________
Telephone # ______________________
INSURANCE INFORMATION
Member Last Name
Member First Name
Gender
Birth Date
For: ________________________________
Date ____________
Mailing Address
Address: ____________________________ Phone _____________
RX
Group Number
Member ID #
Telephone number
PCN#
BIN#
☐ By checking this box, I elect to receive only brand drugs for all prescriptions
in this order, whenever possible. If you have insurance that covers your
prescriptions, that insurance will be billed according to the insurance plan
Dr: _________________________
Dr. _____________________
requirements and program rules, and you will be responsible for the insurance
co-pay/coinsurance as applicable.
Dispense as Written
Substitution Allowed
Physician Name (Please Print) ______________________________
DUE TO FEDERAL REGULATIONS EAGLE PHARMACY CAN ONLY
ACCEPT PRESCRIPTIONS FROM PHYSICIANS
Refill _______
Address __________________________________
DEA# ________________
Telephone # ______________________

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