Patient Insurance Information Form

ADVERTISEMENT

FAX ORDER FORM TO:
877-283-9171
For: ________________________________
Date ____________
To the Physician: Please fax this form to Eagle Pharmacy to help facilitate this
Address: ____________________________ Phone _____________
patient’s prescription order.
RX
To the patient: 1) Fully complete the Patient and Insurance Information
requested below. 2) Have your doctor supply the prescription information
requested using the Rx form on the left. 3) Ask your doctor to fax this form to
the fax number shown above. 4) Make certain a valid credit card is on file with
Eagle Pharmacy to ensure your order may be processed without delay.
PATIENT INFORMATION
Patient Last Name
Patient First Name
Gender
Birth Date
Dr: _________________________
Dr. _____________________
Dispense as Written
Substitution Allowed
List Allergies:
None
Physician Name (Please Print) ______________________________
1.
2.
3.
Physician Last Name
Physician First Name
Physician Telephone
Refill _______
Address __________________________________
DEA# ________________
Telephone # ______________________
INSURANCE INFORMATION
Member Last Name
Member First Name
Gender
Birth Date
For: ________________________________
Date ____________
Mailing Address
Address: ____________________________ Phone _____________
RX
Group Number
Member ID #
Telephone number
PCN#
BIN#
☐ By checking this box, I elect to receive only brand drugs for all prescriptions
in this order, whenever possible. If you have insurance that covers your
prescriptions, that insurance will be billed according to the insurance plan
Dr: _________________________
Dr. _____________________
requirements and program rules, and you will be responsible for the insurance
co-pay/coinsurance as applicable.
Dispense as Written
Substitution Allowed
Physician Name (Please Print) ______________________________
DUE TO FEDERAL REGULATIONS EAGLE PHARMACY CAN ONLY
ACCEPT PRESCRIPTIONS FROM PHYSICIANS
Refill _______
Address __________________________________
DEA# ________________
Telephone # ______________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient Information Sheet-insurance Information Form Patient Information Sheet-insurance Information Form Medical
Patient Demographic & Insurance Information Form Patient Demographic & Insurance Information Form Medical
Patient Registration & Insurance Information Form Patient Registration & Insurance Information Form Medical
Patient Information Form For Dental Service - Primary Insurance Patient Information Form For Dental Service - Primary Insurance Medical
Patient/insurance/health/information Form Patient/insurance/health/information Form Medical
Patient Registration - Insurance/emergency Contact Information Form Patient Registration - Insurance/emergency Contact Information Form Medical
Hipaa Patient Consent Form With Insurance Information Hipaa Patient Consent Form With Insurance Information Legal
Dd Form 2569 - Third Party Collection Program/medical Services Account/ Other Health Insurance Patient Information Dd Form 2569 - Third Party Collection Program/medical Services Account/ Other Health Insurance Patient Information Business
Patient's Information Form Patient's Information Form Legal
Patient Medical Information Form Patient Medical Information Form Medical

Related Categories

Parent category: Medical
Download
Go