Rx Right Source PDF Details

Pharmacies are now able to fill prescriptions from select doctors and hospitals without prior authorization. This new program, Rx Right Source Form, is a way for pharmacies to get their products to patients more quickly. Patients who need medications that are not available through the pharmacy's normal wholesaler can have the prescription filled through this special program. The process is simple-just ask your pharmacist about Rx Right Source Form. The new Rx Right Source Form program allows pharmacies to get their products to patients more quickly. This program is available for patients who need medications that are not available through the pharmacy's normal wholesaler. The process is simple-just ask your pharmacist about Rx Right Source Form.

This knowledge will help you comprehend better the details of the rx right source before you begin filling it out.

QuestionAnswer
Form NameRx Right Source
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshumana pharmacy refill form, humana pharmacy fax form, express scripts physician fax form, rightsource pharmacy fax form

Form Preview Example

Physician Fax Form

206

 

 

Patient Information

 

 

 

Gender

Member ID

 

Date of Birth

 

 

 

 

 

 

 

Male

 

-

 

/

/

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

First Name

 

Last Name

 

 

 

M.I.

Street Number

Street Name

 

 

 

 

 

Apt/Suite #

City

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

-

 

Phone Number

 

Allergies:

No Known

 

Aspirin

Codeine

Penicillin

-

-

 

 

 

 

 

 

 

 

 

Peanuts

Sulfa

 

Other ___________________________

Prescriber First Name

 

Prescriber Information

 

 

 

 

 

Prescriber Last Name

 

 

M.I.

DEA Number

 

NPI Number

 

 

 

 

Street Number

Street Name

 

 

 

 

 

Suite #

City

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

-

 

Phone Number

 

Fax Number

 

 

 

 

-

-

 

-

 

-

 

 

Prescription Information

Must be completed, signed and faxed from provider’s office. This is not valid for CII medications. We will dispense a 90-day supply unless the quantity is otherwise noted or the medication is a controlled substance. In order to require

that a brand-name product be dispensed, the prescriber must write ‘brand medically necessary.’

 

Drug Name and Strength

Directions

Quantity

# of Refills

 

(Alpha & Numeric required

 

 

 

for controlled substances)

 

1.

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

Prescriber Signature (required) _____________________________________________

Today’s Date _____ / _____ /_____

Supervising Prescriber Signature (if applicable) _________________________________

Today’s Date _____ / _____ /_____

Supervising Prescriber DEA Number______________________ Supervising Prescriber NPI Number: _________________

Please fax completed form with secure cover sheet to Humana Pharmacy at 1-800-379-7617

-or-

Send this prescription electronically (eRx) by selecting “Humana Pharmacy Mail Delivery” from the list of pharmacies on your e-prescribing tool. All eRxs from your office will be routed through SureScripts directly to Humana Pharmacy.

GHC 19856A 03/17

PLEASE NOTE: It is standard pharmacy practice to substitute generic equivalents for brand-name drugs whenever possible. Humana Pharmacy will dispense an FDA-approved generic equivalent whenever available, when permitted by the prescriber and allowable by law. If you do not want a generic equivalent, write ‘brand medically necessary,’ which may result in a higher copay for the patient. Your fax can take up to 48 hours to be entered into our system after it is received.

2935ALL0417

How to Edit Rx Right Source Online for Free

The PDF editor was designed with the aim of allowing it to be as simple and easy-to-use as possible. The following steps can certainly make filling up the right source rx fax form quick and easy.

Step 1: The first task is to choose the orange "Get Form Now" button.

Step 2: You're now free to update right source rx fax form. You've got a lot of options with our multifunctional toolbar - you can add, eliminate, or customize the information, highlight the specified sections, as well as carry out many other commands.

These segments will make up the PDF template that you will be completing:

example of blanks in humana prescription fax form

In the field City, State, ZIP Code, Phone Number, Fax Number, Must be completed signed and faxed, Prescription Information, Drug Name and Strength, Directions, Quantity Alpha Numeric required, of Refills, Prescriber Signature required, Supervising Prescriber Signature, Supervising Prescriber DEA Number, and Please fax completed form with provide the particulars which the software demands you to do.

Entering details in humana prescription fax form part 2

Step 3: Hit the button "Done". The PDF file is available to be exported. You can save it to your pc or send it by email.

Step 4: Try to get as many duplicates of the document as possible to avoid future troubles.

Watch Rx Right Source Video Instruction

Rx Right Source isn’t the one you’re looking for?

Related Documents

  • Saco River Education

    "... Co river Education Box 69 Waterboro, ME 04087207247 9000 Option re: co River Education com Dear student. We are grateful for your interest to enroll in our online course for personal support specialists. Once coriv ..."

  • Rut 25 Form

    "... Handout sample is not available for distribution. illinois Department of Revenue mv Rut 25 Vehicle Use Tax Transaction Return Do not Use with Leases ..."

  • Rut 50 Form

    "... This table is used if the step lines have been marked. If you fail to pay your tax by the due date, a late payment penalty will be assessed. Make your check payable to the ..."

  • Rv F1315201 Form

    "... In voice number County name Co number Date of application by authority of the registrar motor vehicles County clerk office ..."

Please rate Rx Right Source

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .