Basinger's Pharmacy

New Prescription Physician Fax Order Form

Use this form to order a new mail service prescription by fax the prescribing physician's office. Member completes section 1, while the physician completes sections 2 and 3. This fax is void unless received directly from physician's office. To contact Basinger's Pharmacy, physician's may call 815-725-1102

Member information - to be completed by member

Member ID Number

(Additional coverage, if applicable)
Secondary Member ID Number

Last Name

First Name

Delivery Address

APt. #

City

State

Zip

Phone Number with Area Code

Date of Birth (mm/dd/yyyy)

Gender M F

Over-the-counter/herbal medications taken regularly:

Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date, please list them here:

Notes to pharmacy:

Physician and prescription information - physician to complete this section

Prescribing Physician Name

Patient Name

DOB

Physician Phone Number with Area Code

Enter prescription detail here or attach your office prescription to the form.

Refills: 1 2 3 Others Dispense as written: Yes

Physician Signature

Date

Physician Fax Number with Area Code

Physician Street Address

City, State, ZIP

NPI

DEA

This document and others if attached contain information from Basinger's Pharmacy that is privileged, confidential and/or may contain protected health information (PHI). We are required to safeguard PHI by applicable law. The information in this document is for the sole use of the person(s) or company named above. Proper consent to disclose PHI between these parties has been obtained. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is againest the law. If you are not the intended recipient, please notify the sender immediately and return the document(s) by mail to Basinger's Pharmacy.

Physician to fax completed order form to Basinger's Pharmacy at 815-725-1102

The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in rellance upon, this information by persons or entities other than the intended recipient is prohibited. This document may contain information covered under the Privacy Act, 5 USC 552(a), and/or the Health Insurance Portability and Accountability Act (PL 104-191) and its various implementing regulations and must be protected in accordance with those provisions. If you received this in error, please contact the sender and delete the material from any computer.

Respiratory

Wheelchairs

Mobility

Aids

Urinary Supplies

Wound Care

Incontinence

Ostomy Supplies

New Prescription