Fillable Exclusive Prescriber Program Referral Form (Mercy Care)

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Exclusive Prescriber Program Referral Form (Mercy Care)

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The Exclusive Prescriber Program Referral Form (Mercy Care) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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EXCLUSIVE PRESCRIBER PROGRAM REFERRAL FORM
INDIVIDUAL SENDING REFERRAL
Referred by:
Contact E-mail:
Referral Date:
MEMBER INFORMATION
Member Name:
Date of Birth:
Member ID: (A#)
BEHAVIORAL HEALTH CLINIC INFORMATION
Clinic Name:
Address:
Treating Prescriber:
Phone:
Prescriber’s E-Mail:
Fax:
PCP INFORMATION
PCP Name:
Address:
Phone:
Fax:
Other Involved Medical Prescriber:
Address:
Phone:
Fax
BEHAVIORAL HEALTH & MEDICAL INFORMATION
Behavioral Health Diagnoses:
Medical Diagnoses:
All prescribed medications:
Number of suicide attempts or overdose with controlled substance in the last 6 months:
REASON FOR REFERRAL
To make a referral, please e-mail the completed form to: MCP-PharmLock2@AETNA.com
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Exclusive Prescriber Program Referral Form (Mercy Care)

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Completed 31 July 2021

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