Specialty Pharmacy Services Enrollment Form
Fax Referral To: 1-800-323-2445 Phone: 1-800-237-2767 Email Referral To: customerservicefax@caremark.com
Six Simple Steps to Submitting a Referral
1 PATIENT INFORMATION (Complete or include demographic sheet)
Patient Name: ____________________________Address: ________________________City, State, ZIP: __________________________
Preferred Contact Methods: Phone (to primary # provided below) Text (to cell # provided below) Email (to email provided below)
Note: Carrier charges may apply. If unable to contact via text or email, Specialty Pharmacy will attempt to contact by phone.
Primary Phone: ________________ Alternate Phone: ________________DOB: ________________ Gender: Male Female
Email: ____________________________________Last Four of SSN: ________________Primary Language: ______________________
2 PRESCRIBER INFORMATION
Prescriber’s Name: ____________________________________ State License #: _____________________________________________
NPI #: _______________ DEA #: _______________ Group or Hospital: ____________________________________________________
Address: _____________________________________________ City, State, ZIP: ____________________________________________
Phone: ___________________ Fax___________________ Contact Person: _________________ Contact’s Phone: _________________
3 INSURANCE INFORMATION Please fax copy of prescription and insurance cards with this form, if available (front and back)
4 DIAGNOSIS AND CLINICAL INFORMATION
Needs by Date: ________ Ship to: Patient Office Other: ___________
Diagnosis (ICD-10):
Code: ________ Description: ____________________________ Code: ________ Description: ____________________________
Code: ________ Description: ____________________________ Code: ________ Description: ____________________________
For additional ICD-10 information, please visit CVS Specialty Healthcare Professionals Website
https://www.cvsspecialty.com/wps/portal/specialty/healthcare-professionals/about-us
Patient Clinical Information:
Allergies: ___________________________________________ Height: ______in/cm Weight: ______lb/kg
Concomitant Medications: _________________________________________________________________________________________
Additional Comments: ____________________________________________________________________________________________
Nursing:
Specialty pharmacy to coordinate injection training/home health nurse visit as necessary? Yes No
Site of Care: MD office Infusion Clinic Outpatient Health Home Health
Injection training not necessary. Date training occurred: ____________
Reason: MD office training patient Pt already independent Referred by MD to alternate trainer
5 PRESCRIPTION INFORMATION
Other: ______________ Other: __________ Other: _________________________________
Quantity: _________
Refills: ___________
Other: ______________ Other: __________ Other: _________________________________
Refills: ___________
Other: ______________ Other: __________ Other: _________________________________
Refills: ___________
Other: ______________ Other: __________ Other: _________________________________
Refills: ___________
Other: ______________ Other: __________ Other: _________________________________
Quantity: _________
Refills: ___________
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
The information provided above is true and accurate to the best of my knowledge, with supporting documentation in the patient’s medical record. By signing
below, I hereby authorize CVS Specialty Pharmacy and/or its affiliate pharmacies to complete and submit prior authorization (PA) requests to payors for the
prescribed medication for this patient and to attach this Enrollment Form to the PA request as my signature.
CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated
recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any
review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify the
sender immediately by telephone and destroy all copies of this communication and any attachments.
Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not
affiliated with CVS Specialty and/or one of its affiliates.
©2018 CVS Specialty and/or one of its affiliates. 75-36127A 101018
Phone: 1-800-237-2767
Fax Referral To: 1-800-323-2445
Email Referral To: customerservicefax@caremark.com
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
