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.

Form NameRx Right Source
Form Length1 pages
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




Patient Information





Member ID


Date of Birth




























First Name


Last Name





Street Number

Street Name






Apt/Suite #






ZIP Code











Phone Number



No Known



















Other ___________________________

Prescriber First Name


Prescriber Information






Prescriber Last Name




DEA Number


NPI Number





Street Number

Street Name






Suite #






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



# of Refills


(Alpha & Numeric required




for controlled substances)
































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


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.


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.

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