[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306843-105":53,"doc-detail-306843-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","the-lilly-cares-diabetes-prescription-fax-form","The Lilly Cares Diabetes Prescription FAX Form","","The Lilly Cares Foundation Patient Assistance Program Diabetes Prescription FAX Form collects patient and prescriber details required to transmit a diabetes prescription to an approved pharmacy. It includes sections for patient identity, contact and shipping address, drug allergies and other medications, authorization language for Lilly Cares to act on the patient’s behalf, and selections for specific insulin or diabetes medications with quantity, maximum daily dose, and refills. The form requires a signature from the prescriber and printed prescriber information.",{"@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/the-lilly-cares-diabetes-prescription-fax-form/306843/",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/the-lilly-cares-diabetes-prescription-fax-form/306843.png","ImageObject",442,249,{"name":88,"@type":89},"Kyle","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":40},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does the form collect for the patient?","Question",{"text":108,"@type":109},"It collects patient name, date of birth, phone, address details, drug allergies, and other medications, plus the ship-to address if it differs from the patient address.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is the prescriber’s authorization used?",{"text":113,"@type":109},"The patient authorizes Lilly Cares to act on the patient’s behalf to transmit the prescription to the appropriate pharmacy and to support electronic prescription submission through the selected pharmacy in the eRx software.",{"name":115,"@type":106,"acceptedAnswer":116},"What dosing details can be completed on the form?",{"text":117,"@type":109},"For each selected medication, the form provides options for quantity per month supply, maximum dose per day, and refills, along with specific packaging or pen/vial formats when applicable.","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},306843,1790285339,{"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":40,"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},3985741905716,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","# The Lilly Cares® Foundation Patient Assistance Program (“Lilly Cares”) Diabetes Prescription FAX Form\n\nPatient Name:   Date of Birth:   Today’s Date:    \nAddress:    \nCity:   State:   Zip Code:   Phone:   \nDrug Allergies:    \nOther Medications:    \nShip to Address (if different from patient address above, No P.O. Box or third-party vendor):  \nAddress:    \nCity:   State:   Zip Code:   Phone:    \nRx: I authorize Lilly Cares to act on my behalf for the purpose of transmitting this prescription to the appropriate pharmacy. To submit an electronicprescription, please select Neovance Specialty Pharmacy (NPI 1780811125) in your eRx software.  \nBasaglar® (insulin glargine injection)  \n􀂅 U-100 KwikPen®  \nSig:  \n\n| Quantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \u003Cbr>Max dose per day: Refills: \\#  \u003Cbr>Humalog® Mix 75/25™ (insulin lispro protamineand insulin lispro injectable suspension)  \u003Cbr>􀂅 U-100 vial 􀂅 U-100 KwikPen®  \u003Cbr>Sig:   |\n| --- |\n| Quantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \u003Cbr>Max dose per day: Refills: \\#Humulin® R (insulin human injection)  \u003Cbr>􀂅 U-100 vial  \u003Cbr>Sig:   |\n| Quantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \u003Cbr>Max dose per day: Refills: \\#Trulicity® (dulaglutide) injection  \u003Cbr>􀂅 0.75 mg/0.5 mL Pen 􀂅 3.0 mg/0.5 mL Pen  \u003Cbr>􀂅 1.5mg/0.5 mLPen 􀂅 4.5 mg/0.5 mL PenSig:   |\n\nQuantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \nMax dose per day:__________ Refills: \\#___________  \nHumalog® (insulin lispro injection)  \n􀂅 U-100 vial 􀂅 U-100 cartridge  \n􀂅 U-100 KwikPen® 􀂅 U-200 KwikPen®  \n􀂅 U-100 KwikPen® JuniorSig:  \nQuantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \nMax dose per day: Refills: \\#  \nHumulin® N (isophane insulin human suspension)  \n􀂅 U-100 vial 􀂅 U-100 KwikPen®  \nSig:  \nQuantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \nMax dose per day: Refills: \\#  \nHumulin® RU-500 (insulin human injection)  \n􀂅 U-500KwikPen®  \nSig:  \n___________________________________________  \nQuantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \nMax dose per day: Refills: \\#  \nHumalog® Mix 50/50™ (insulin lisproprotamineand insulin lispro injectable suspension)  \n􀂅 U-100 KwikPen®  \nSig:  \nQuantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \nMax dose per day: Refills: \\#Humulin® 70/30 (human insulinisophanesuspensionand human insulin injection)  \n􀂅 U-100 vial 􀂅 U-100 KwikPen®  \nSig:  \nQuantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \nMax dose per day: Refills: \\#Lyumjev™ (insulin lispro-aabc)  \n􀂅 U-100 vial 􀂅 U-100 KwikPen®  \n􀂅 U-200 KwikPen®Sig:  \n___________________________________________  \nQuantity (per month supply): 􀂅 4 (max) 􀂅 3 􀂅 2 􀂅 1  \nMax dose per day: Refills: \\#  \nYour state may require that prescriptions follow certain content requirements or use a particular form. By signing below, you certify that you are abiding bylawsapplicable to prescriptions and authorized prescribers inthe states in which you are prescribing. I authorize Lilly Cares to act on my behalf forthe limited purposes oftransmitting this order for prescription medication.  \nSignature (REQUIRED):      \nDispense as written Substitution/brand exchange permitted  \nRubber stamps, signature by other office personnel for the prescriber, and computer-generated signatures will not be accepted.  \nPrinted Prescriber Name and Title:   FAX:   \nState License Number and State:  NPI\\#:   Phone: Prescriber Office/Clinic Name and Shipping Address (No PO Box):     \n________________________________________________________________________________________________________________","cbCaionSMyr6Tx60","https://ap.wps.com/l/cbCaionSMyr6Tx60","pdf",175038,"English","# Patient information\n# Shipping address\n# Authorization and pharmacy submission\n# Medication selections and dosing\n# Prescriber certification and signature","[{\"question\":\"What information does the form collect for the patient?\",\"answer\":\"It collects patient name, date of birth, phone, address details, drug allergies, and other medications, plus the ship-to address if it differs from the patient address.\"},{\"question\":\"How is the prescriber’s authorization used?\",\"answer\":\"The patient authorizes Lilly Cares to act on the patient’s behalf to transmit the prescription to the appropriate pharmacy and to support electronic prescription submission through the selected pharmacy in the eRx software.\"},{\"question\":\"What dosing details can be completed on the form?\",\"answer\":\"For each selected medication, the form provides options for quantity per month supply, maximum dose per day, and refills, along with specific packaging or pen/vial formats when applicable.\"}]","The Lilly Cares Diabetes Prescription FAX Form | PDF",1789841762]