RX Form Request

Prescription Headquarters, Inc
Pharmacy Service for the Injured

RX Form Request

RX Request

Please fill out this form completely. You can fax your prescription to 877-938-0102.

For questions, please call 800-585-4298

First Name: Middle Initial:
Last Name:

	Workers Comp Injury
	Personal Injury
Gender:	MaleFemale

Address:
Address:
City, St, Zip:
Phone Number:
Alternative Phone:
Date of Birth:
Social Security Number:
Date of Injury:
Body Part Injured:
Workers Comp Insurance Carrier:
Phone Number:
Claim Number:
Employer Name:
Employer Phone Number:
Physician Name:
Physician Phone Number:
Attorney Name:
Attorney Phone Number:
Comments:

I certify; by placing my name in the box, that the information on this form is accurate and complete. I authorize payment of medical benefits to Prescription Headquarters. I hereby authorize any doctor, hospital, attorney or other provider who participated in my care and treatment to release to Prescription Headquarters all medical or other information requested for processing of my claim(s)