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e-Prescribe Submission Form Web 1st #

Short Description
(Please be very specific and copy into the
ticket being opened)
Full Description
(Please provide a narrative of the problem and
copy into the ticket being opened)
Pharmacy Name (Req’d)
Pharmacy Phone Number (helpful) PHONE:
FAX:
Date Transmitted (Req’d)
Time Transmitted
Successfully Transmitted?
MRN/Patient Name (Req’d) NAME:
MRN:
Provider Full Name (Req’d)
DEA or NPI# DEA:
NPI:
Medication (Req’d)
New Rx or Refill?
Controlled Substance?
Print Queue Message Type Script
Fax

Did the script complete in print


queue?
Print Queue Message ID
(found in print queue details, upper left corner)
Did provider receive an RxXmit RxXmit Failure Message:
Failure task?
Onset Details:
(Double click all that apply. Selected entries
will appear in caps – double click to toggle
back to lowercase)
Frequency
(Double click all that apply. Selected entries
will appear in caps – double click to toggle
back to lowercase)
User/Devices Affected PROVIDER
(Double click all that apply. Selected entries Pharmacy Device(s) Please specify:
will appear in caps – double click to toggle
back to lowercase)
Is this issue preventing you from YES
sending prescriptions?
Specific to Organization, Site or USF HEALTH
Location? If so, please provide
details.
New Site? NO
Error Message Text If an error was encountered, please click button and copy/paste all info at
the end of this document.

Please paste screen shots associated with “Steps to Reproduce” below:

Please paste error message text below: