Specialty Pharmacy Referral Resources

Download a referral form for specialty pharmacy orders. A blank form can be used for all insurance plans. Or, choose a form for a specific payor listed below.

Click the name of the form you need. The form will open in a separate window. You can save the form to your computer or print out a copy of the form. Then complete the form and fax it to the location listed on the form.

• Blank form
• BlueCross BlueShield of Kansas City
• BlueCross BlueShield of Florida – Health Options
• BlueCross BlueShield of Western New York
• BlueCross BlueShield of Northeastern New York
• HealthNow New York Inc.
• BlueCross BlueShield of North Carolina
• UnitedHealthcare
• Capital BlueCross

All forms are in PDF format. You must have Adobe Reader to view PDF documents. Click the Get Adobe Reader button to download a copy if necessary.