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Rx Referral Forms

If you have any questions, we would love to help.

Referring a patient to DirectRx Pharmacy is EASY. If you are a licensed prescriber, follow these 3 simple steps:

  1. Select the appropriate referral form.
  2. Complete the referral form online and print a hard copy
  3. Fax the completed referral form, signed by the prescriber, to DirectRx at (877) 892-4007.

You are now part of an integrated circle of care that includes you, your patient and a single point of contact at DirectRx. When you refer a patient to DirectRx, you can expect us to provide the following benefits:

  • Immediate confirmation of your patient referral
  • Status updates
  • Thorough and timely processing of the patient’s information and prescription, and a complete benefit investigation
  • Assistance with prior authorization forms
  • Communication with the patient to:
    • Inform them of receipt of their doctor’s prescription by DirectRx
    • Explain the prior authorization process, if applicable
    • Notify of out-of-pocket costs
    • Obtain permission and assist in enrollment of copay assistance programs or completing funding applications when needed
  • Pharmacist counseling for your patient with 24 hour on-call assistance availability

DirectRx Pharmacy is designed to deliver the ultimate experience in customer care to patients in need of specialty medications. Through carefully coordinated treatment plans and collaborative partnerships with physicians like you, DirectRx will ensure that patients embark on their journey to better health with no delays.

Bronchiectasis – Referral Form
Crohn’s/Ulcerative Colitis – Referral Form
HIV/Aids – Referral Form
Kynmobi Referral Form
Multiple Sclerosis – Referral Form
Oncology – Referral Form
Organ Transplant – Referral Form
Psoriasis – Referral Form
Respiratory – Referral Form
Rheumatology A-N – Referral Form
Rheumatology O-Z – Referral Form
Samsca – Referral Form