Prescription and Pharmacy Benefit Management: Refer and Save By Phone: 770-676-7337 By Fax: 877-457-1345 By Email: RxReferrals@SunriseMedicalSolutions.com Online: complete the form below Referrer InformationReferrer Name*Referrer Email*Referrer Company*Referrer Phone*Claim InformationAdjuster InformationAdjuster Name*Adjuster Email*Adjuster Company*Adjuster Phone*Adjuster AddressNurse Case Manager InformationNCM NameNCM EmailNCM CompanyNCM PhonePatient InformationNameGenderMaleFemaleOtherDate of BirthSocial Security Number(last four digits only)AddressCityStateSelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip CodePhoneAlternate PhoneClaim NumberDate of InjuryState of JurisdictionSelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPrescription AuthorizationMedical ApprovalOne TimeOngoingScript and RefillsState of Jurisdiction ApprovalYesNoPharmacy InformationPharmacy NamePharmacy PhoneContact Person (if available)Prescription Number (if available)Prescriber InformationPrescriber NameDEA and/or NPIPrescriber PhoneAttorney InformationAttorney NameAttorney PhoneAdditional InformationAuthorized MedicationsFile Upload Prescription and other supporting referral documents may be attached electronically below.Submit