PRESCRIPTION INTAKE FORM
Fax: 800-263-0251 • Phone: 800-541-4959 • Mon.- Fri. 8 a.m. to 7 p.m.
CONFIDENTIAL_HEALTH_INFORMATION:_Healthcare information is personal information related to a person’s healthcare. It is being faxed to you after appropriate authorization or under circumstances that don’t require authorization. You are obligated to maintain it in a safe, secure and confidential
manner. Re-disclosure of this information is prohibited unless permitted by law or appropriate customer/patient authorization is obtained. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state laws.
IMPORTANT_WARNING:_This is intended for the use of the person or entity to whom it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employer or agent
responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message in error, please notify us immediately.
Drug names are the property of their respective owners. Revised 7/22/2015
PATIENT’s Last Name First Name Gender DOB
Address City State ZIP Allergies Diagnosis Code & Mutation
Email Phone#: Home Phone#: Work/Mobile Parent/Guardian Name Phone#
( ) ( ) ( )
Primary Insurance Patient’s ID# Cardholder’s Name (if not patient) Provider Service Phone# Group#
( )
Secondary Insurance Patient’s ID# Cardholder’s Name (if not patient) Provider Service Phone# Group#
( )
Pharmacy Benefit RxBin# RxID# Rx Group# Pharmacist Help Desk Phone# Rx PCN#
( )
Please indicate desired dosage, directions, day supply or quantity, refills, and DAW.
DOSAGE: Please specify mutation
150mg Mutation:__________
1 tablet every 12 hours OTHER:
Orkambi (lumacaftor/ivacaftor)
200mg/125mg Mutation:__________
2 tablets every 12 hours OTHER:
BID Every Other Month OTHER:
150mg *Sterile Water & Syringe below
BID Every Other Month OTHER:
5ml/vial *Reconstitute with _________ ml
BID Every Other Month OTHER:
BID Every Other Month OTHER:
BID Every Other Month OTHER:
TOBI (tobramycin) Podhaler
BID Every Other Month OTHER:
Hyper-Sal 7% (sodium
chloride)
Pulmosal 7% (pH+) (sodium
chloride)
Care Center/Physician’s Office Phone# Fax# DEA# NPI# Medicaid Provider#
Prescriber’s Name (PRINT) Date
Prescriber’s Signature (Substitution Permitted)
Prescriber’s Signature (Dispense As Written)
*** To promote quality, efficiency, and
accuracy, please submit prescriptions
to “Cystic Fibrosis Services-TX” via
your E-Prescribing software***
