Cataramaran Fax Order Form PDF Details

Cataramaran Fax Order Form is a company that specializes in providing the best catamaran products for customers. We are committed to customer satisfaction and will work hard to ensure your needs are met with our products. We offer a variety of different types of catamarans, such as: 1) Cataraft-Rafts 2) Catarafts 3) Rafts 4) Rigid Inflatable Boats 5) Rigid Hulled Boats 6) Self-Bailing Rigid Hulled Boats 7). The type you select will depend on what you need it for and how much money you're willing to spend.

Below is the information concerning the file you were in search of to fill out. It will show you the amount of time you'll need to fill out cataramaran fax order form, exactly what fields you need to fill in, and so forth.

QuestionAnswer
Form NameCataramaran Fax Order Form
Form Length1 pages
Fillable?Yes
Fillable fields28
Avg. time to fill out5 min 51 sec
Other namesingenio home delivery pharmacy mail order fax form, form catamaran form, fax form catamaran, catamaran medicare prior auth form

Form Preview Example

NEW PRESCRIPTION FAX FORM

Member Information

Cardholder ID #:

86125 *86125*

(Include all characters. Leave box blank for spaces.)

Cardholder name:

STEP 1 Complete all information below. Prescriber Information

Prescriber Name:

Fax#:

Not for CII prescriptions

STEP 2 Fill in or attach prescription below

Prescriber Name

Address

City, State, Zip

Write or stamp here

(Fill out one form for each Rx)

Patient Name: ___________________________________

Drug:

Strength: ____________________

Quantity: ____________________

Directions:

Refills: ________(up to 3 refills)

X

Date: / /

 

(Stamps are not accepted. Signature required.)

In order for a brand name product to be dispensed, the prescriber must handwrite "brand necessary" or "brand medically necessary" in the space below.

NPI #:

(NPI required for all prescriptions)

DEA #:

 

(DEA required for CIII-CV prescriptions)

Telephone #:

-

-

Patient Information

Date of birth:

Telephone #:

Ship to address:

STEP 3

Indicate number of medications on this page.

Have questions?

Call 1 866 834-0449.

For reporting allergies or

medical conditions, press option 5

(Monday-Friday 9:00 am - 8:00 pm Eastern.)

STEP 4

Sign this prescription and fax to:

1 866 996-4921

¨Fax from the prescriber's secure fax line.

¨Do not fax with a cover sheet.

¨Incomplete forms will cause a delay in processing.

When applicable PRINT Supervising Physician name here é

*86125*

Confidentiality Notice: This communication and any attachments are intended solely for the use of the addressee named above and contains confidential and legally privileged information. If you are not the intended recipient, any dissemination, distribution or copying is strictly prohibited. If you received this communication in error, please notify Catamaran Home Delivery by fax or phone immediately. Catamaran Home Delivery facsimile machines are secure and in compliance with HIPAA privacy standards.

The provision of the information requested in this form is for your patient's benefit. Catamaran Home Delivery does not compensate for completing this form.

How to Edit Cataramaran Fax Order Form Online for Free

We were developing our PDF editor with the notion of allowing it to be as quick to work with as it can be. That's the reason the procedure of filling in the form catamaran will be smooth perform all of these steps:

Step 1: Search for the button "Get Form Here" on the following webpage and hit it.

Step 2: Now you will be within the file edit page. You can include, alter, highlight, check, cross, add or delete areas or words.

You'll have to provide the following information in order to fill out the file:

stage 1 to completing fax form catamaran

Include the asked particulars in the (Fill out one form for each Rx), Patient Name:, STEP 3, Drug:, Indicate number of medications on, Strength:, Quantity:, Directions:, Refills:, (up to 3 refills), Date:, (Stamps are not accepted, When applicable PRINT Supervising, Have questions, and Call 1 866 834-0449 segment.

Finishing fax form catamaran stage 2

The application will ask for more information with the intention to effortlessly complete the area When applicable PRINT Supervising, Confidentiality Notice: This, and The provision of the information.

Filling out fax form catamaran part 3

Step 3: As soon as you click on the Done button, the finished document is conveniently transferable to any kind of of your devices. Or alternatively, you may send it by means of email.

Step 4: You should generate as many duplicates of your file as you can to stay away from possible troubles.

Watch Cataramaran Fax Order Form Video Instruction

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