Get the free Cipro XR Quantity Supply PAB Fax Form

This document is a prior authorization request form for the medication Cipro XR, intended for healthcare providers to complete and fax to the Prior Authorization of Benefits (PAB) Center.

How to fill out cipro xr quantity supply

How to fill out Cipro XR Quantity Supply PAB Fax Form

1. Obtain the Cipro XR Quantity Supply PAB Fax Form from your healthcare provider or pharmacy.
2. Fill in your personal information at the top of the form, including your name, address, and contact number.
3. Enter the prescribing physician's details, including their name, contact information, and NPI number.
4. Specify the patient's information, including their name and date of birth.
5. Indicate the medication requested (Cipro XR) along with the dosage and quantity needed.
6. Complete any insurance information required, including policy numbers and provider names.
7. Review the form for accuracy and completeness.
8. Sign the form if required, acknowledging the information is correct.
9. Fax the completed form to the designated number provided on the form.

Who needs Cipro XR Quantity Supply PAB Fax Form?

1. Patients who have been prescribed Cipro XR and require a quantity supply for their medication.
2. Healthcare providers or pharmacists handling medication requests for patients needing Cipro XR.

People Also Ask about

How many days should I take 500mg for diarrhea?

Table 1.6. 1: Acute diarrhea antibiotic treatment recommendations 1 Antibiotic1DoseDuration 500 mg BID 3 days Levofloxacin 500 mg QD 1–3 days4 Rifamycin SV5 388 mg BID 3 days Rifaximin5 200 mg TID 3 days3 more rows • Apr 23, 2025

What is the difference between and XR?

A recently developed extended (modified)-release formulation of ( XR or XL) provides higher maximum plasma concentrations with lower inter-patient variability than the conventional, immediate-release, twice-daily formulation.

Is XR being discontinued?

† An extended-release oral tablet form of known as XR has been discontinued by the drug's manufacturer. (“Extended release” means the drug is released slowly over time in the body.)

How many tablets of 500mg should I take?

The usual dose of tablets or liquid is 250mg to 750mg twice a day. For some infections, you might only need to take a single dose. Doses are usually lower for children and people with kidney problems.

How is supplied?

It's often prescribed as an oral tablet and liquid suspension. In most cases, is taken every 12 hours. Your specific dosage and length of treatment can change depending on your symptoms, infection type, and body weight. is available as a lower-cost generic.

Is 500mg a strong antibiotic?

Bottom Line. is an effective antibiotic that treats a wide variety of infections; however, it should not be given to children aged less than 18. In adults, it should be reserved for infections that are not treated by other antibiotics. Severe side effects include tendinitis and tendon rupture.

Can 500mg be taken twice a day?

is administered orally twice daily for 7 to 14 days or at least two days after signs and symptoms of the infection are over. The recommended oral dose regimen is 250 mg twice daily to treat mild to moderate and 500 mg twice daily for severe or complicated urinary tract infections.

How many tablets of 500mg?

Adults — 250 to 500 milligrams (mg) 2 times a day, taken every 12 hours for 7 to 14 days. Children — Dose is based on body weight and must be determined by your doctor. The dose is usually 10 to 20 milligrams (mg) per kilogram (kg) of body weight every 12 hours for 10 to 21 days.

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What is Cipro XR Quantity Supply PAB Fax Form?

Cipro XR Quantity Supply PAB Fax Form is a document used for requesting a quantity supply of the prescription medication Ciprofloxacin XR, which is typically used to treat bacterial infections.

Who is required to file Cipro XR Quantity Supply PAB Fax Form?

Healthcare providers, such as doctors and pharmacists, who are prescribing or dispensing Cipro XR may be required to file the Cipro XR Quantity Supply PAB Fax Form as part of the prior authorization process.

How to fill out Cipro XR Quantity Supply PAB Fax Form?

To fill out the Cipro XR Quantity Supply PAB Fax Form, ensure you provide patient information, prescribing physician details, medication dosage, quantity requested, and any required clinical information supporting the request.

What is the purpose of Cipro XR Quantity Supply PAB Fax Form?

The purpose of the Cipro XR Quantity Supply PAB Fax Form is to obtain authorization for the supply of Cipro XR from insurance providers, ensuring that the medication is covered and accessible for the patient.

What information must be reported on Cipro XR Quantity Supply PAB Fax Form?

The information that must be reported on the Cipro XR Quantity Supply PAB Fax Form includes patient name, date of birth, insurance details, prescribing physician's information, medication details (dosage and quantity), and clinical justification for the requested quantity.