Jessica Miller

 
 21/06/10 12:49 FROM- CWFMD 
 936-703-5455 
 T-256 P0098/0111 F-240 
 Fax completed form to: 1-855-633-7673 
 SILVER/SCRIPT Submitted 
 Questions, please call: 1-866-235-5660 
 24 hours a day 7 days a week 
 (TTY users call: 1-866-236-1069) 
 online 5.18.16 
 Request for Coverage of a Non-Formulary Drug 
 Patient Information 
 Prescriber and Pharmacy Information 
 Name Jessica Miller 
 Name Joshua Dubose 
 Member ID 
 Specialty Family Practice 
 Medicare ID 
 DEA 
 Date of Birth 99/07/30 
 Sex: M 
 NPI 
 1,700997665 
 Address 14570 TRERO LANE 
 Address 804 West Montgomery 
 City WILLIS 
 City Willis 
 State TX 
 ZIP 77378 
 State TX 
 ZIP 77378 
 Fax (936) 890-9008 
 Nursing Home Resident? 
 YES / NO 
 Pharmacy name Walgreens 
 Home care patient? 
 YES / NO 
 If no available formulary alternatives have been previously tried, please check this box. 
 I 
 attest that the information provided 1900 othis fonm nature and accurate as of this 
 date: 
 Prescriber's signature: 
 Date: 21/11/13 
 5246-24762a 011912 
 Y0080_APLS_50096_2013 
 Name: Jessica Miller 
 DOB: 99/07/30 
 Date:
