| ADEA-001 |
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| Controlled Substance Prescription Fax Form |
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Now Available
DEA enforcement actions in 2009 signal that chart orders in long-term care are no longer accepted as a valid prescription for a controlled substance.
To fill and dispense a controlled substance order, in a non-emergency situation, a pharmacist must first have a prescription written and signed by a practitioner or the practitioner’s agent.
Pharmacies can provide this form to their client nursing facilities to help expedite the receipt of a valid, non-emergency prescription for CII-V controlled substances.
How it is used:- Nursing staff calls the prescriber to request a controlled substance and documents the verbal order received from a prescriber
- Nursing staff faxes the form to the prescriber
- The prescriber writes the prescription (as required by law), signs and faxes the authorized prescription on to the pharmacy to be filled
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| Features: |
- Nursing staff portion of form documents verbal order including drug, patient/facility information, prescriber information and other vital information
- Prescriber portion of form documents facility/patient profile information, full medication order which the prescriber must write (dose and form, route, directions for use, indication, quantity to dispense), the prescriber signature and DEA number
- Space is provided to write, label or stamp pharmacy name and fax number
- Can be customized - special wording, colors, pre-print pharmacy name/fax number/logo. Call the MED-PASS pharmacy team for details and prices.
- Routing bar code added for electronic document management utilizing the Integra DocuTrack system
- This form was co-developed exclusively by the American Society of Consultant Pharmacists and MED-PASS, Inc.. It has not been approved, endorsed or authorized by the DEA.
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| Specifications: |
| 8-1/2 x 11, handwritten, 100 per pad |
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| Free Monthly Reorder Reminder Program - Click here to eliminate needless overnight emergency shipping of medical records. |
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