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RightSourceRx
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 (using one of the fax forms below) to us at 1-877-405-7940. RightSourceRx Specialty will only accept faxes from providers.

MS
(252 KB) Download PDF
English
Hepatitis C
(252 KB) Download PDF
English
RA-Psoriasis-Ankylosing Spondylitis-Crohn's
(252 KB) Download PDF
English
Osteoarthritis
(252 KB) Download PDF
English
Oral Oncology
(252 KB) Download PDF
English
Growth Hormone
(252 KB) Download PDF
English
Increlex
(252 KB) Download PDF
English
General Prescription
(252 KB) Download PDF
English
Printable Health Insurance Page From Humana