Fax Forms

An Official Pennsylvania Government Website

Translate

DHS

Department of Human Services

Services

Find a Document

About

For Providers

Begin Main Content Area

Pharmacy Service Fax Forms

For best experience, please use a desktop computer to access this page.

Filter Results By

Content Search

Number of Items:

Drug ⇳

Alpha. ⇳

Acne Agents, Topical Form

Actemra Form

Aliskiren Agents Form

Alpha-1 Proteinase Inhibitors Form

Alzheimer's Agents Form

Ampyra Form

Analgesics, Non-Opioid Barbiturate Combinations Form

Analgesics, Opioids Long Acting Form

Analgesics, Opioids Short Acting Form

Androgenic Agents Form

Angiotensin Modulator Combinations Form

Angiotensin Modulators Form

Antibiotics, Inhaled Form

Anticonvulsants Form

Antidepressants, Other Form

Antidepressants, SSRIs Form

Antiemetics-Antivertigo Agents Form

Antifungals, Oral Form

Antifungals, Topical Form

Antihistamines, Minimally Sedating Form

Antihypertensives, Sympatholytics Form

Antihyperuricemics Form

Antimigraine Agents, Other – CGRP Inhibitors

Antimigraine Agents, Other Form

Antimigraine Agents, Triptans Form

Antiparkinson’s Agents Form

Antipsoriatics, Oral Form

Antipsoriatics, Topical Form

Antipsychotics Form

Antivirals, Oral Form

Antivirals, Topical Form

Anxiolytics Form

Arcalyst Form

Aubagio Form

Austedo Form

Beta Blockers Form

Bile Salts Form

Bladder Relaxants Form

Bone Resorption Suppression Agents Form

Botulinum Toxins Form

BPH Agents Form

Brand Medically Necessary Form

Brineura Form

Bronchodilators, Beta Agonist Form

Calcium Channel Blockers Form

Cesamet Form

Cholbam Form

Cimzia Form

Cinqair Form

Colony Stimulating Factors Form

Compounded Prescriptions Form

COPD Agents Form

Corlanor Form

Cosentyx Form

Daliresp Form

Diabetic Meters and Strips Form

Dupixent Form

Eliquis Form

Enbrel Form

Entresto Form

Entyvio Form

Epinephrine, Self-Injected Form

Erythropoiesis Stimulating Agents Form

Evista Form

Exondys 51 Form

Fasenra Form

Fluoroquinolones, Oral Form

Forteo and Tymlos Form

GI Motility, Constipation Form

GI Motility, Diarrhea Form

Gilenya Form

H.P. Acthar Gel Form

Hepatitis B Agents Form

Hepatitis C Agents Form

Hereditary Angioedema Agents Form

Histamine II Receptor Blockers Form

HIV AIDS Form

Humira Form

Hypoglycemics, Alpha-Glucosidase Inhibitors Form

Hypoglycemics, Incretin Enhancer Form

Hypoglycemics, Incretin Mimetics Form

Hypoglycemics, Insulin Form

Hypoglycemics, Meglitinides Form

Hypoglycemics, Metformins Form

Hypoglycemics, SGLT2 Form

Hypoglycemics, Sulfonylureas Form

Hypoglycemics, TZDs Form

Ilaris Form

Ilumya Form

Immune Globulins Form

Immunomodulators, Atopic Dermatitis Form

Immunomodulators, Topical Form

Ingrezza Form

Inhaled Glucocorticoids Form

Injectable Anticoagulants Form

Injectable Bone Resorption Suppression Agents Form

Intra-Articular Hyaluronates Form

Intranasal Rhinitis Agents Form

Iron, Parenteral Form

Juxtapid and Kynamro Form

Schools That Teach
Jobs That Pay
Government That Works

For best experience, please use a desktop computer to access this page.

Filter Results By

Content Search

Governor's Goals

Government that Works

Jobs that Pay

Schools that Teach

Government that Works

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z