EFTA00313925.pdf

&WU Langone INCDICAl CI '..H Pharmacy Information With the installation of Epic, the new electronic medical record system, at this practice, your doctor Is now able to e- prescribe. This means that any prescriptions the doctor may give you today will be automatically routed to the pharmacy of your choice and we will no longer have to provide you with handwritten prescriptions. In addition, when you run out of refills on your medication, the pharmacist can now electronically send renewal requests to this office for approval. **Note: Controlled medications are not eligible for e-prescribing. Please complete the Information below if you are interested in e-prescribing. Patient Name: Te-FF0-0\) Preferred Pharmacy Alternate Pharmacy Name of Pharmacy: kicaLmAL maat2 marl Name of Pharmacy: Address: CO ' -PuA44\cl laST 1st ibie Address: a Le MA NROA.) AVC City: nIti vtl \JOCK City: hjea- vt.1 •104K State: State: Zip Code: N Zip Code: Phone Number: Phone Number: Fax Number: Fax Number: Laboratory Information Please indicate by placing a checkmark next to one of the options below to identify your preferred laboratory. Some insurance plans require that covered patients utilize specific laboratories; failure to follow their guidelines can lead to bills that become the patient's responsibility. If you do not know which laboratory to select, please contact your insurance carrier. If you do not select a laboratory, the practice will default any lab tests to NYU laboratory. NYU Lab Other External Location Please provide name of external location: EFTA00313925