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

Allergy

Allergy Referral Form

Hepatitis

Hepatitis B Referral Form

Hepatitis C Referral Form

Oncology

Oncology Referral Form

Dermatology

Dermatology Blank Form

Dermatology Referral Form (A-H)

Dermatology Referral Form (I-Z)

HIV

HIV Referral Form

Opioid Withdrawal Syndrome

Lucemyra Referral Form

Gastroenterology

Gastroenterology Referral Form

Immunoglobulin (IG)

IG Referral Form

Rheumatology

Osteoporosis Referral Form

Rheumatoid Arthritis Referral Form (A-N)

Rheumatoid Arthritis Referral Form (O-Z)

Multiple Sclerosis

Multiple Sclerosis Referral Form

Weight Management

Weight Management Form

Once We Receive The Completed Referral Form, The Owl 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 health care professional of the prescription status.
  • Contact the patient to coordinate pick-up or delivery of the medication.
  • Pharmacist will discuss with the patient their medication(s), how to maintain adherence, monitor and report side effects.