Registration forms and pen for signing up for RightSourceRx Specialty mail-order prescriptions

Specialty Drug Forms

Get started with RightSourceRx Specialty by downloading and printing the forms below.

Member Forms

RightSourceRx Specialty Member Registration and Order Form: (108 KB)Download PDF; English

Consent for Release of Protected Health Information: (252 KB) Download PDF; English

Physician Fax Forms

Ask your doctor to fill out and fax your new prescription with the drug-specific fax form to us at 1-877-405-7940. RightSourceRx Specialty will only accept faxes from providers.

Amevive: (252 KB) Download PDF; English
Avonex: (252 KB) Download PDF; English
Betaseron: (252 KB) Download PDF; English
Cimzia: (252 KB) Download PDF; English
Copaxone: (252 KB) Download PDF; English
Copegus: (252 KB) Download PDF; English
Eligard: (252 KB) Download PDF; English
Enbrel: (252 KB) Download PDF; English
Genotropin: (252 KB) Download PDF; English
Gleevec: (252 KB) Download PDF; English
Humatrope: (252 KB) Download PDF; English
Humira: (252 KB) Download PDF; English
Infergen: (252 KB) Download PDF; English
Intron-A: (252 KB) Download PDF; English
Kineret: (252 KB) Download PDF; English
Lupron: (252 KB) Download PDF; English
Nexavar: (252 KB) Download PDF; English
Norditropin: (252 KB) Download PDF; English
Nutropin: (252 KB) Download PDF; English
Omnitrope: (252 KB) Download PDF; English
Orencia: (252 KB) Download PDF; English
Pegasys: (252 KB) Download PDF; English

Peg-Intron: (252 KB) Download PDF; English
Rebetol: (252 KB) Download PDF; English
Rebif: (252 KB) Download PDF; English
Remicade: (252 KB) Download PDF; English
RibaPak: (252 KB) Download PDF; English
Ribasphere: (252 KB) Download PDF; English
RibaTab: (252 KB) Download PDF; English
Ribavirin: (252 KB) Download PDF; English
Saizen: (252 KB) Download PDF; English
Serostim: (252 KB) Download PDF; English
Sprycel: (252 KB) Download PDF; English
Sutent: (252 KB) Download PDF; English
Tarceva: (252 KB) Download PDF; English
Targretin: (252 KB) Download PDF; English
Tasigna: (252 KB) Download PDF; English
Tev-Tropin: (252 KB) Download PDF; English
Thalomid: (252 KB) Download PDF; English
Trelstar: (252 KB) Download PDF; English
Tykerb: (252 KB) Download PDF; English
Zolinza: (252 KB) Download PDF; English
Zorbtive: (252 KB) Download PDF; English