Scribd Logo
Upload

Welcome to Scribd!

  • 183 views

    Prescription Request Form

    Uploaded by

    Jeffrey Wooliscroft
    This document provides instructions for patients and healthcare providers to have prescriptions filled through Mark Cuban Cost Plus Drug Company. It outlines a 4-step process: 1) Patients create an account including contact and insurance information. 2) Patients provide the names of medications they want prescribed. 3) Patients share this form with their provider. 4) Providers submit prescriptions electronically, by phone, or by fax including the patient's email address.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Prescription Request Form

    Uploaded by

    Jeffrey Wooliscroft
    183 views1 page
    This document provides instructions for patients and healthcare providers to have prescriptions filled through Mark Cuban Cost Plus Drug Company. It outlines a 4-step process: 1) Patients create an account including contact and insurance information. 2) Patients provide the names of medications they want prescribed. 3) Patients share this form with their provider. 4) Providers submit prescriptions electronically, by phone, or by fax including the patient's email address.

    Original Title

    PrescriptionRequestForm

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides instructions for patients and healthcare providers to have prescriptions filled through Mark Cuban Cost Plus Drug Company. It outlines a 4-step process: 1) Patients create an account including contact and insurance information. 2) Patients provide the names of medications they want prescribed. 3) Patients share this form with their provider. 4) Providers submit prescriptions electronically, by phone, or by fax including the patient's email address.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    183 views1 page

    Prescription Request Form

    Uploaded by

    Jeffrey Wooliscroft
    This document provides instructions for patients and healthcare providers to have prescriptions filled through Mark Cuban Cost Plus Drug Company. It outlines a 4-step process: 1) Patients create an account including contact and insurance information. 2) Patients provide the names of medications they want prescribed. 3) Patients share this form with their provider. 4) Providers submit prescriptions electronically, by phone, or by fax including the patient's email address.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Prescriber Cover Page

    Powered by:

    To have your prescriptions filled, it’s as simple as 1, 2, 3. Please complete steps #1–3 below and
    share this form with your healthcare provider to complete step #4.

    FOR PATIENTS

    Step 1: Create your account


    In order for prescriptions to be filled through Mark Cuban Cost Plus Drug Company, patients must first create a user account.

    To get started, please visit: https://costplusdrugs.com/create-account/

    Step 2: Provide patient information


    Email Address The email address associated with the

    Required Cost Plus Drug Co. user account
    Last Name First Name MI

    Delivery Address Apt., Ste. #

    City State ZIP Code Phone Number



    (with area code)

    Date of Birth
 Sex (assigned at birth)


    (mm/dd/yyyy)
    Female Male

    Healthcare
    Healthcare

    Provider Name Provider Phone

    Step 3: Share this form and the prescription drugs you’d like us to fill
    Look for the drugs on the Mark Cuban Cost Plus Drugs site you’d like your doctor to prescribe at: https://costplusdrugs.com/medications/

    Please note we are unable to fill any prescription drugs not on our website.
    After talking to your doctor, send this form and request the prescriptions
    Write the names of the drugs you would like prescriptions for below, and tell your doctor:

    FOR PROVIDERS

    Step 4: Providers: Please Submit the Prescriptions – in one of 3 ways


    This document contains information from
    1 eRx (electronically): 2 By Phone: Truepill Pharmacy that is privileged,
    confidential and/or may contain protected
    Perform pharmacy search for: 
 1 (833) 926-3384 health information (PHI). We are required
    to safeguard PHI by applicable law. The
    Speak directly with our pharmacy staff.
    “Mark Cuban Cost Plus
 information in this document is for the
    sole use of the person(s) or company
    Drug Company” named above. Proper consent to disclose
    PHI between these parties has been
    NCPDP ID: 4940208 3 By Fax: obtained. If you received this document by
    mistake, please know that sharing,
    1 (650) 683-9775 copying, distributing or using information
    IMPORTANT: Providers MUST INCLUDE THE in this document is against the law. If you
    PATIENT’S EMAIL ADDRESS (see box above). 
 If submitting by fax, please USE THIS are not the intended recipient, please
    Our pharmacy system requires an email address DOCUMENT AS A COVER PAGE along with notify the sender immediately and return
    the signed prescription page(s). the document(s) by mail to Truepill
    to match new prescriptions with patients. Pharmacy, 3121 Diablo Ave, Hayward, CA
    94545.
    v11 - June 2022

    You might also like

    pFad - Phonifier reborn

    Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

    Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


    Alternative Proxies:

    Alternative Proxy

    pFad Proxy

    pFad v3 Proxy

    pFad v4 Proxy