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 Information

Referrer Name*

Referrer Email*

Referrer Company*

Referrer Phone*

Claim Information

Adjuster Information

Adjuster Name*

Adjuster Email*

Adjuster Company*

Adjuster Phone*

Adjuster Address

Nurse Case Manager Information

NCM Name

NCM Email

NCM Company

NCM Phone

Patient Information

Name

Gender

MaleFemaleOther

Date of Birth

Social Security Number

(last four digits only)

Address

City

State

Zip Code

Phone

Alternate Phone

Claim Number

Date of Injury

State of Jurisdiction

Prescription Authorization

Medical Approval

One TimeOngoingScript and Refills

State of Jurisdiction Approval

YesNo

Pharmacy Information

Pharmacy Name

Pharmacy Phone

Contact Person (if available)

Prescription Number (if available)

Prescriber Information

Prescriber Name

DEA and/or NPI

Prescriber Phone

Attorney Information

Attorney Name

Attorney Phone

Additional Information

Authorized Medications

File Upload

Prescription and other supporting referral documents may be attached electronically below.