Medicaid Order - ASRX

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A RUSH can be applied at any time and will be shipped in 3-5 business days for a fee. You can find the order confirmation sent via e-mail. View pricing here

Medicaid Order Form

Please fill out the information which you want to print on the pad.

Medicaid Prescription Order Form

Provider First Name

Provider Last Name

Title

Practice Name

To add multiple providers or locations, please scroll down to the bottom of the order form.

Print Practice Name on Pad?

Yes (Print on Pad)

DEA License Number

Print DEA Number on Pad?

Yes (Print on Pad)

DEA Exp. Date

State License Number

Print State License Number on Pad?

Yes (Print on Pad)

State Exp. Date

NPI Number

Print NPI Number on Pad?

Yes (Print on Pad)

Email

Print Email on Pad?

Yes (Print on Pad)

Address

City

State

Zipcode

Print Address on Pad?

Yes (Print on Pad)

Phone

Print Phone on Pad?

Yes (Print on Pad)

Fax

Print Fax on Pad?

Yes (Print on Pad)

Contact Name

Contact Email

Contact Phone

Shipping Address (If Different)

Shipping Address (If Different)

Address

City

State

Zipcode

Shipping Method

Payment Method

PO Number

Your Invoice will be included with your shipment. Please see our Prices for pricing details.

Rush Order?

Rush Order? (Ships in 2-3 business days, call for service fee)

Prescription Type:

Prescription Format

Quantity

Number of Providers

Number of Locations

Provider Name 2

DEA Number 2

License Number 2

NPI Number 2

Provider Name 3

DEA Number 3

License Number 3

NPI Number 3

Provider Name 4

DEA Number 4

License Number 4

NPI Number 4

Provider Name 5

DEA Number 5

License Number 5

NPI Number 5

Provider Name 6

DEA Number 6

License Number 6

NPI Number 6

Provider Name 7

DEA Number 7

License Number 7

NPI Number 7

Provider Name 8

DEA Number 8

License Number 8

NPI Number 8

Provider Name 9

DEA Number 9

License Number 9

NPI Number 9

Provider Name 10

DEA Number 10

License Number 10

NPI Number 10

Provider Name 11

DEA Number 11

License Number 11

NPI Number 11

Provider Name 12

DEA Number 12

License Number 12

NPI Number 12

Provider Name 13

DEA Number 13

License Number 13

NPI Number 13

Provider Name 14

DEA Number 14

License Number 14

NPI Number 14

Provider Name 15

DEA Number 15

License Number 15

NPI Number 15

Provider Name 16

DEA Number 16

License Number 16

NPI Number 16

Provider Name 17

DEA Number 17

License Number 17

NPI Number 17

Provider Name 18

DEA Number 18

License Number 18

NPI Number 18

Provider Name 19

DEA Number 19

License Number 19

NPI Number 19

Provider Name 20

DEA Number 20

License Number 20

NPI Number 20

Location Name 2

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 3

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 4

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 5

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 6

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 7

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 8

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 9

Phone:

Fax:

Address :

City:

Postal/Zip:

Location Name 10

Phone:

Fax:

Address :

City:

Postal/Zip:

Need Proof?

Need Proof (Optional)

Add Files:

File Upload

Additional Comments:

A RUSH can be applied at any time for a quicker turnaround time for a fee. You can find the order confirmation sent via e-mail.

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