Sav Rx Prior Authorization Form Details

Sav Rx Order Form, an online prescription and pharmacy management tool, simplifies the process of filling prescriptions and helps you stay organized. With Sav Rx Order Form, you can create a profile for each family member and store all of their medications in one place. Plus, our secure order form makes it easy to request refills and track your medication history.

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QuestionAnswer
Form NameSav Rx Order Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessavrx pa form, save rx prior authorization form, rx form, sav rx prior authorization form

Form Preview Example

Sav-Rx Prescription Services

P.O. Box 8

Fremont, NE. 68026

1-800-228-3108

SAV-RX MAIL ORDER FORM

Name:

Address:

Daytime Phone:

ID#:

Group #:

 

 

City

State

 

Zip

 

Evening Phone:

 

 

 

 

 

 

Patient Name (if prescription is for other than the cardholder)

Patient Date of Birth:

NEW PRESCRIPTION

1.Complete the information above

2.Include your original prescription(s) in an envelope

3.Include Credit Card information or payment

* Note: Your physician may phone in your order to 1-800- 228-3108 or fax your order to 1-888-810-1394

REFILL

1.Complete the information above

2.Place refill sticker on this sheet or refill Rx# and drug name. The refill sticker is on the right side of the prescription information that arrived with your previous prescription order.

3.Include Credit Card information or payment

4.To expedite your refill order, you may call 1-800- 228-3108 to order by phone.

Place Refill Sticker(s) here or complete the information.

Refill Rx#_______________________________________

Drug Name______________________________________

Refill Rx#_______________________________________

Drug Name______________________________________

Refill Rx#_______________________________________

Drug Name______________________________________

Sav-Rx does not hold prescriptions. Please send only prescriptions to be ordered immediately. Once an order has been processed, it cannot be stopped. We will not accept returns of accurately dispensed medications.

Please charge my Credit CardCredit Card Expiration Date:

Check One!!!!!!!!!!!!!!!!!!

!!!!!!!!!

!!!!!!!!!!

 

!!!!!!!!!!!!!!!!!!!!"Month:______ ______ Year:______ ______!

Credit Card Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardholder Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

____________________________________________________________________________ ______________________

Personal Check or Money Order enclosed. If providing payment by personal check, make payable to Sav-Rx and provide your ID# on the check. Mail payment and prescription to Sav-Rx P.O. Box 8 Fremont, Ne. 68026

PRE-PAYMENT IS REQUIRED FOR ALL ORDERS. IF YOU NEED CURRENT PRICING PLEASE CALL 1-800-228-3108

TO SPEAK DIRECTLY WITH A CUSTOMER SERVICE REPRESENATIVE. ANY ORDERS RECEIVED WITHOUT PAYMENT COULD BE DELAYED.

By checking this box, I elect to receive brand name drugs for all prescriptions in this order. I understand I am responsible for the brand co-payment, which may be higher.