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AUSTEDOPRESCRIPTION AND SERVICE REQUEST FORM(deutetrabenazine) tabletsPlease fax completed form to 18442576126 For questions, call 18008878100STEP 1: Patient Information/History (please print) o VA

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How to fill out prescription and service request

01

To fill out a prescription, follow these steps:

02

Begin by writing the date at the top of the prescription.

03

Include the patient's full name, address, and date of birth.

04

Write down the name of the medication, dosage instructions, and quantity.

05

Indicate the frequency and duration of use.

06

Include the prescriber's name, contact information, and professional credentials.

07

Sign the prescription at the bottom to confirm your authorization.

08

To fill out a service request, follow these steps:

09

Start by writing the date at the top of the request form.

10

Include your personal information such as name, address, and contact details.

11

Specify the type of service you require in detail.

12

Provide any supporting documents or medical records if necessary.

13

Indicate your preferred date and time for the service to be performed.

14

Sign the request form at the bottom to authorize the service.

15

Make sure to double-check all the information before submitting either the prescription or service request.

Who needs prescription and service request?

01

Prescriptions and service requests are needed by individuals who require medical treatment, medication, or specific healthcare services.

02

This can include patients seeking treatment for various diseases, illnesses, or conditions.

03

Doctors, physicians, and healthcare professionals also need prescriptions to properly administer medications to their patients.

04

Service requests can be submitted by patients who require specialized medical services, home healthcare, laboratory tests, or any other specific healthcare service.

05

So, anyone with a medical need or seeking healthcare services can benefit from prescriptions and service requests.

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What is prescription and service request?

Prescription is a written order from a healthcare provider for a specific treatment or medication. Service request is a formal request for a particular service to be provided.

Who is required to file prescription and service request?

Healthcare providers are required to file prescription and service request.

How to fill out prescription and service request?

Prescriptions and service requests should be filled out accurately with all necessary information, including patient details, treatment or service requested, and provider information.

What is the purpose of prescription and service request?

The purpose of prescription and service request is to ensure that patients receive the appropriate treatment or service as requested by their healthcare provider.

What information must be reported on prescription and service request?

Prescriptions and service requests must include patient information, provider information, treatment/service requested, and any relevant details.

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