Exactus Pharmacy Form PDF Details

Exactus Pharmacy is a specialty pharmacy that offers comprehensive and innovative services to patients with complex medical conditions. We provide individualized care to each patient, and work closely with prescribers and healthcare providers to ensure that our patients receive the best possible care. Our formularies are tailored to meet the specific needs of our patients, and we offer a variety of programs and services to help them manage their medications. We are committed to providing quality care and service, and our Patients First philosophy drives everything we do. Visit Exactus Pharmacy today for all your specialty pharmacy needs!

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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