Pharmacy Prescription Form PDF Details

Did you know that in the United States there are two types of prescriptions? The first is a standard prescription which is a written order from a physician for drugs or other medical treatments for a particular patient. The second type is an electronic prescription, which is an order transmitted electronically from the prescriber to the pharmacist. Both types of prescriptions are legally valid, but each has its own benefits and drawbacks. In this blog post, we'll take a closer look at pharmacy prescription forms so that you can understand the difference between them.

This knowledge can help you grasp better the details of the pharmacy prescription form before you begin filling it out.

QuestionAnswer
Form NamePharmacy Prescription Form
Form Length1 pages
Fillable?Yes
Fillable fields58
Avg. time to fill out11 min 55 sec
Other nameshttps mailrx wellcare com, wellcare pharmacy, wellcare online pharmacy, does wellcare have mail order pharmacy

Form Preview Example

Mail-Order Pharmacy Prescription Form

Phone: 866-740-2539

Please fax completed form to WSP Mail-Order Pharmacy: 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

Drug Name & Strength

Directions

Quantity

Number of Refills

DAW

1.

2.

3.

4.

5.

6.

IMPORTANT NOTICE: It is standard pharmacy practice to substitute generic equivalents for brand name medications. WellCare Specialty Pharmacy Mail-Order Pharmacy 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:

DEA:

NPI:

 

Address:

 

 

City:

State:

Zip:

Phone:

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 STRICLTY PROHBITED. If you have received this message in error, please notify us immediately.

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