Select the link below to download the condition-specific enrollment form:
Prescribers may send prescriptions by fax, phone, e-prescribe or mail. For initial or refill prescription requests, please fax the prescription or order form.
E-Prescribe: NCPDP 3679252
Mail: 7835 Freedom Ave NW, North Canton, OH 44720
Condition-specific forms are included below. You may also contact Customer Service at 877-437-9012. Fax all completed forms to 877-309-0687.