Prescription
Medical doctors, psychologists, social workers, pharmacists, politicians and other related professionals

What would a good prescription or management plan look like?

How should a prescription look?

Details of physician/medical doctor

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Details of resident/patient

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Medication

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Eyeglass prescription

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Here are further guidelines.

Preventive
    Exercise Recommendations
    Nutrition Recommendations
    Counseling Recommendations
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Curative
    Exercise Recommendations
    Nutrition Recommendations
    Counseling Recommendations
    Diagnostic tests
    Medication
    Interventional cardiology, gastroenterology, dialysis, Ophthalmology, Obstetrics & Gynecology, etc.
    Rare surgery
    _______
Would you like to add anything?
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Can you make us wiser? How?
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Anyone found blocking communication at any level will face consequences. Prescription

Prescription medication, a drug available only by a medical prescription
Medical prescription, a plan of care written by a physician or other health care professional
Eyeglass prescription, written by an ophthalmologist or an optometrist/physician.
Please provide information about your Patient.

Patient Name

Patient DOB

Prescriber Information (required)

Prescriber Name

Prescriber Phone

Prescriber Fax

Prescriber

Is patient being discharged from hospital or institution on these medications?

Contact Person for This Request Prior Authorization Request Drug #1

Medication Name & Strength Drug #1

Dosage Form #1

If Available Quantity #1

Directions for Use Drug #1

Including Length of Treatment

Diagnosis or ICD-9 Code Drug #1

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