Rx Forms – altScripts Specialty Pharmacy

Prescription Referral Forms

This section is for prescribing practitioners only. Patients must bring an original prescription to the pharmacy and cannot fax referral forms. Faxed prescriptions will only be accepted from a licensed practitioner.

Alcohol / Opioid Dependency

AODA_SUD Referral Form

Dermatology

Dermatology Blank Form

Dermatology Referral Form

Gastroenterology

Gastroenterology Referral Form

General

Referral Form

Hepatitis

Hepatitis B Referral Form

Hepatitis C Referral Form

HIV

HIV Referral Form

Immunoglobulin (Ig)

Ig Referral Form

Multiple Sclerosis

Multiple Sclerosis Referral Form (A-L)

Multiple Sclerosis Referral Form (M -Z)

Oncology

Oncology Referral Form

Pulmonology

Pulmonology Referral Form

Rheumatology

Osteoporosis Referral Form

Rheumatoid Arthritis Referral Form (A-O)

Rheumatoid Arthritis Referral Form (P-Z)

Once we receive the completed referral form, the altScripts Specialty team will:

Verify insurance coverage and file the claim with the insurance provider.
Provide prior authorization and financial assistance support to ensure patient access.
Notify the patient and physician of the prescription status.
Contact the patient to coordinate pick-up or delivery of the medication.
The pharmacist will educate the patient on their medication(s), including how to maintain adherence and monitor side effects.