[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-286770-105":53,"doc-detail-286770-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","caremark-patient-referral-form","Caremark Patient Referral Form","","This document is a formal Patient Referral Form used by healthcare providers to transmit prescription medication information to Caremark. It includes comprehensive sections for physician and patient contact details, primary and secondary insurance information, specific medication order details such as strength, dosage, and frequency, as well as clinical information including diagnosis codes and patient vitals. The form facilitates administrative processes for medication ordering, shipping preferences, and patient-specific coordination of care.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/caremark-patient-referral-form/286770/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/caremark-patient-referral-form/286770.png","ImageObject",442,249,{"name":88,"@type":89},"Terk","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-28","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should a completed patient referral form be submitted to Caremark?","Question",{"text":108,"@type":109},"Completed forms can be faxed to Caremark at (800) 323-2445.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What contact information is required for the ordering physician?",{"text":113,"@type":109},"The form requires the physician's name, office address, contact telephone and fax numbers, state license number, DEA number, and UPIN number.",{"name":115,"@type":106,"acceptedAnswer":116},"What details are needed for the prescription medication section?",{"text":117,"@type":109},"You must provide the medication name, strength, dosage instructions (dose, route, frequency), quantity or length of treatment, and the number of refills.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},286770,1790084654,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Please fax completed form to Caremark at (800) 323-2445. To order by phone, call CaremarkConnect toll-free  \n(800) 237-2767.  \nThe prescription has been electronically transmitted or faxed by:   \n(Faxing Agents Full Name)  \nP a t i e n t R e f e r r a l F o r m  \n\n|  |\n| --- |\n|  |\n\nPhysician Information  \nPatient Information  \nPhysician’s Name: Patient’s Name:  \n\n| Address: |  | Address: |\n| --- | --- | --- |\n| City: State: Zip: |  | City: State: Zip: |\n| Office Contact: |  | Date of Birth: Sex:  M  F |\n| Telephone: Fax: |  | Patient ID \\#: |\n| State License \\#: |  | Daytime Telephone \\#: Evening Telephone \\#: |\n| DEA \\#: UPIN\\#: |  | Emergency Contact & Relation: Contacts Telephone\\#: |\n| Prima ry Insurance Information |  | \u003Cbr>Secondary Insurance Information\u003Cbr>|\n|  |  | Insurance Company: |\n|  |  | Insured’s Name: |\n| Insured Date of Birth: |  | Alternate ID \\#: Date of Birth: |\n| Subscriber ID \\#: |  | Subscriber ID \\#: |\n| Group ID \\#: |  | Group ID \\#: |\n| Relationship Code / Relationship to Insured: |  | Relationship Code / Relationship to Insured: |\n| Prescription Medication | St ren gth | Direct ions ( D o s e / R o u t e / F r e q u e n c y ) Q uantity/Length |\n| 1)\u003Cbr>2) 3) Refills: Physician’s Signature:\u003Cbr>Date of Prescription: DAW:\u003Cbr>Additional Patient Information  \u003Cbr>|  |  |\n| Primary Diagnosis: |  | ICD9 Diagnosis Code: |\n| Secondary Diagnosis: |  | ICD9 Diagnosis Code: |\n| HCPC Code: |  | CPT Code: |\n| Height: Weight: |  | Allergies: |\n| Shipping Information |  |  |\n| Ship to:  Physician If You Selected Other:\u003Cbr> Patient’s Home  Other ( Enter address information at right å )\u003Cbr>Address: City: State: Zip:\u003Cbr>Target Delivery Date: Refill Date: Area Code and Phone: |  |  |","cbCaipHhOqlWmGEo","https://ap.wps.com/l/cbCaipHhOqlWmGEo","pdf",53754,"English","# Physician Information\n# Patient Information\n# Insurance Information\n# Prescription Medication Details\n# Clinical and Shipping Information","[{\"question\":\"How should a completed patient referral form be submitted to Caremark?\",\"answer\":\"Completed forms can be faxed to Caremark at (800) 323-2445.\"},{\"question\":\"What contact information is required for the ordering physician?\",\"answer\":\"The form requires the physician's name, office address, contact telephone and fax numbers, state license number, DEA number, and UPIN number.\"},{\"question\":\"What details are needed for the prescription medication section?\",\"answer\":\"You must provide the medication name, strength, dosage instructions (dose, route, frequency), quantity or length of treatment, and the number of refills.\"}]","Caremark Patient Referral Form | PDF",1789631530]