Hrsa Prescription Form PDF Details

Understanding how to fill out the correct paperwork is essential when it comes to getting prescriptions filled. If you're looking for help on this matter, then you've come to the right place. Here we will break down what exactly HRSA's prescription form is used for and how best to go about filling it out so that you can get the medications needed in a timely manner. So whether you are just learning about this process or need a refresher course on submitting your HRSA forms accurately, keep reading!

QuestionAnswer
Form NameHrsa Prescription Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshealth and recovery service administration prescription form, dshs hrsa prescription form, hca 13 794, hrsa form washington state

Form Preview Example

HEALTH AND RECOVERY SERVICES ADMINISTRATION (HRSA) PRESCRIPTION FORM

This prescription is valid for one (1) year from date signed.

SECTION I

PATIENT’S NAME

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

DIAGNOSIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENGTH OF NEED

 

 

 

 

 

 

 

 

 

 

 

Indicate rental if applicable

Less than 6 months

 

Greater than 6 months

Number of months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II

 

 

 

 

 

 

ITEM

 

 

QUANTITY

 

 

SUPPLIES – FREQUENCY OF USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III

 

 

 

 

 

 

PHYSICIAN’S PRINTED NAME

 

 

 

TELEPHONE NUMBER

 

FAX NUMBER

REFERRING PHYSICIAN’S NUMBER

 

 

 

 

 

 

 

 

 

 

PHYSICIAN’S ADDRESS

 

 

 

 

 

 

CITY

STATE

ZIP CODE

I certify that I am the physician identified in Section III of this form and that the medical necessity information in Section I and II is true, accurate, and complete, to the best of my knowledge. I understand that any falsification, omission, or concealment of material fact in those sections may subject me to civil or criminal liability. (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTED).

PHYSICIAN’S SIGNATURE

DATE SIGNED

 

 

DSHS 13-794 (11/2006)

 

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