Fillable New Prescription Fax Form printable pdf download

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Mail Service Pharmacy

Fax # 1-800-378-0323

FastStart

New Prescription Fax Form

If you would like to send a maintenance prescription to CVS Caremark Mail Service Pharmacy for

your patient, please complete this form and fax it to the number above or ePrescribe (see step 4).

Please complete the 4 steps below.

Step 1: Patient Information

Patient Name: ______________________________________

DOB: ______________________

Address: __________________________________________

Phone: (_____) _____ - _______

City, ST, ZIP: ________________________________________________________________________

CVS Caremark

Prescription

Member ID#: _________________

Benefit Provider _______________________________

Allergy Information: __________________________________________________________________

Step 2: Prescription Information

Prescription Date:

___________________

DRUG NAME

STRENGTH

DIRECTIONS

QUANTITY

REFILLS

1. ____________________ ____________ ____________________

90 days or _______

1 year or _____

2. ____________________ ____________ ____________________

90 days or _______

1 year or _____

3. ____________________ ____________ ____________________

90 days or _______

1 year or _____

4. ____________________ ____________ ____________________

90 days or _______

1 year or _____

Prescriber signature: ____________________________ Prescriber signature: ____________________________

May substitute

Dispense as written

______________________________

Transmitted by:

(Full name if other than physician)

Step 3: Physician Information Required

Dr. Name: _________________________________________

Phone: (______) ______ - ________

Address: __________________________________________

Fax: (______) ______ - ________

City, ST, ZIP: ________________________________________________________________________

NPI #: ___________________________

DEA #

:________________________

(If controlled substance)

Step 4: Fax this form to 1-800-378-0323

Or e-Prescribe to CVS Caremark Mail Order Electronic, NCPDP ID 322038

9501 East Shea Blvd, Scottsdale, AZ 85260

If you are not the intended recipient of this FAX, you are hereby notified that any disclosure, copying or distributing is prohibited. If you have

received this FAX in error or if you would like to talk to our staff, please notify us by phone toll-free at 1-800-378-5697. Plan participant privacy

is important to us. Our employees are trained regarding the appropriate way to handle our plan participants’ private health information.

106-13946a WEB

MD FAX WEB UNAUTH 0215

New Prescription Fax Form

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