Exactus Pharmacy Form PDF Details

The Exactus Pharmacy form is a crucial document designed to streamline the process of obtaining prescription medications through mail service, ensuring that individuals can receive their medications conveniently and efficiently. At its core, the form collects member information, including Member ID, patient name, date of birth, gender, shipping address, and any known allergies, facilitating a personalized and safe service. The form specifically requires completion and faxing from a provider's office, emphasizing that it is not valid for Schedule II controlled substances and mandates a 90-day supply quantity unless stated otherwise. Exactus Pharmacy Solutions pledges not to auto-ship medications without verification from the member, underlining their commitment to consent and communication. Prescription details such as drug name, strength, direction for use, quantity, and the number of refills are clearly outlined, with a specific section dedicated to prescriber information to assure accuracy and responsibility in dispensing. The form acknowledges the standard pharmacy practice of substituting brand name medications with FDA-approved generic equivalents, whenever possible, advising members to contact customer service for any exceptions or inquiries about this policy. Moreover, the document includes an important warning regarding the confidentiality and intended recepient of the information, highlighting the legal protections and considerations in handling sensitive health information. Through the meticulous collection and handling of both prescribing and patient information, the Exactus Pharmacy form plays a vital role in the secure and effective delivery of mail-order medications.

QuestionAnswer
Form NameExactus Pharmacy Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesplease pharmacy form template, please pharmacy form pdf, mail intended prescription, mail pharmacy intended fill

Form Preview Example

Mail Service Pharmacy Prescription Form

Phone: 866-740-2539

Please fax completed form to Exactus Pharmacy Solutions Mail Service: 877-709-1694.

Member Information

Member ID:

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

Gender: Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shipping Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Allergies: No Known

Aspirin

Codeine

Penicillin

Peanuts

Sulfa

Other

 

 

 

 

 

 

 

 

 

 

Prescription Information

Fax the completed form from the provider office. This is not valid for CII prescriptions. Please make sure the quantity is for a 90-day supply unless otherwise noted.

Our Promise: We will never auto-ship medications and will verify all prescriptions with member before shipping.

Rx

1.

Drug Name & Strength

Directions

Quantity

Number of Refills

DAW

2.

3.

4.

5.

6.

IMPORTANT NOTICE: It is standard pharmacy practice to substitute generic equivalents for brand name medications. Exactus Pharmacy Solutions Mail Service will dispense an FDA-approved generic equivalent whenever available, when permitted by the prescriber and allowed by law. If you do not want a generic equivalent or have questions regarding your mail order prescription, please call customer service at 866-740-2539.

Prescriber Information

MD/ARNP Name:

Date:

 

 

 

 

DEA:

NPI:

 

 

 

 

Address:

 

 

 

 

 

City:

State:

Zip:

 

 

 

Phone Number:

Fax:

 

 

 

 

MD/ARNP Signature:

 

 

 

 

 

IMPORTANT WARNING: This message is intended for the use of the person or entity to whom it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this information is STRICTLY PROHIBITED. If you have received this message in error, please notify us immediately.

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NA020528_PRO_FRM_ENG

©WellCare2012 NA_10_12

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