Fillable Specialty Medication Prescription/referral Form printable pdf download

Tel: (800) 906-7798 / Fax: (877) 381-3806

SPECIALTY MEDICATION

Prescription/Referral Form

Please complete this form (PRINT) in its entirety. Be sure to

enclose any necessary documentation, labs, insurance cards, etc.

PATIENT DEMOGRAPHICS:

PRESCRIBER INFORMATION:

WEIGHT: _______  lbs  kg HEIGHT________

SPECIALTY: ________________________

SEX: M F

PRESCRIBER’S NAME: _____________________________________________________

PATIENT NAME: ______________________________________________

CLINIC NAME: ___________________________________________________________

DDRESS: ________________________________________________________________

ADDRESS: _________________________________ SUITE #: ____________

ADDRESS 2: ______________________________________________________________

CITY: ____________________________________ STATE: ______ ZIP: _____________

CITY: _______________________________________ STATE: ______ ZIP: __________

LICENSE #: _______________________________ DEA#: ________________________

HOME PHONE: ________________________ WORK PHONE: ______________________

NPI#: ___________________________ EMAIL: ________________________________

CELL PHONE: ________________________ EMAIL: ______________________________

CONTACT NAME & TITLE: __________________________________________________

DATE OF BIRTH (mm/dd/yyyy): _______________ SOCIAL SECURITY #: ____________

PHONE: ________________________________ FAX: ___________________________

ALLERGIES: ______________________________________________________________

INSURANCE INFORMATION:

Please include copies of medical & prescription cards (front/back).

PRIMARY INSURANCE: _______________________________________ POLICY HOLDER: ____________________________________________ POLICY #: _____________________

GROUP #: __________________________________ EMPLOYER: _______________________________________ INSURANCE PHONE #: ___________________________________

SECONDARY INSURANCE: ____________________________________ POLICY HOLDER: ____________________________________________ POLICY #: _____________________

GROUP #: __________________________________ EMPLOYER: _______________________________________ INSURANCE PHONE #: ___________________________________

CLINICAL INFORMATION:

Diagnosis: _____________________________________________

ICD-9: ____________________

Rx INFORMATION:

Drug Name and Strength: _________________________________________________________________

DOSE: ___________________________________________ SIG:____________________________________________________

 90 day  30 day other:_____

Number of doses per week: ________

Number of Refill(s):________

Days Supply:

Rx INFORMATION:

Drug Name and Strength: _________________________________________________________________

DOSE: ___________________________________________ SIG:____________________________________________________

 90 day  30 day other:_____

Number of doses per week: ________

Number of Refill(s):________

Days Supply:

Rx INFORMATION:

Drug Name and Strength: _________________________________________________________________

DOSE: ___________________________________________ SIG:____________________________________________________

 90 day  30 day other:_____

Number of doses per week: ________

Number of Refill(s):________

Days Supply:

Rx INFORMATION:

Drug Name and Strength: _________________________________________________________________

DOSE: ___________________________________________ SIG:____________________________________________________

 90 day  30 day other:_____

Number of doses per week: ________

Number of Refill(s):________

Days Supply:

By signing below, I authorize Acro Pharmaceutical Services (“ACRO”) to: Collect my health condition and prescription information from my doctor, healthcare provider, health

insurer or pharmacist in order to ensure its accuracy and completeness and to communicate to the patient support program of the pharmaceutical manufacturer (the “Program”); and

contact my insurer, other potential funding sources, social workers, patient advocacy organizations, and patient assistance programs on my behalf to determine if I am eligible for

assistance. I hereby authorize my doctor, healthcare provider, health insurer or pharmacist to provide my health condition and prescription information to Acro and to the Program. I

understand that I may revoke this authorization at anytime by sending a letter to Acro at 313 Henderson Drive, Sharon Hill, PA 19079. Patient’s Signature: __________________



DELIVER MEDICATION TO:

PATIENT’S HOME

PHYSICIAN’S OFFICE

OTHER: ______________________________

REQUESTED DATE OF DELIVERY: ______________________________________

PRESCRIBER’S PRINTED NAME: ___________________________________

PRESCRIBER’S SIGNATURE: ___________________________________________

DATE: ________________________

SUBSTITUTION ALLOWED

Thank you for using ACRO Pharmaceutical Services!

Fax completed form to: (877) 381-3806 /

Important Notice:

This communication contains information that is confidential and protected from disclosure. If the reader of this message is not the intended recipient, employee or agent responsible for

delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in

error, please reply to the sender that you have received the message in error and destroy this copy.

ACRO.Gen.080510