MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES

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TB MEDICATION REQUEST

NEW	REFILL
FOR NEW ORDERS CALL 800-392-5586 OR FAX 660-886-2121

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S 	PLEASE MAIL OR FAX REFILL REQUESTS

HEALTH UNIT	REQUEST DATE	
CLIENT INFORMATION	
NAME	DATE OF BIRTH	WEIGHT	
ADDRESS (STREET, CITY, ZIP CODE)	SOCIAL SECURITY #	
PRESCRIPTION INSURANCE INFORMATION (ATTACH COPY OF CARD AT BOTTOM OF PAGE IF AVAILABLE)	
INSURANCE PLAN (ie: MEDICAID, BLUE CHOICE, PCS, UNITED HEALTHCARE)	CLIENT’S RELATIONSHIP TO CARDHOLDER (ie: SELF, SPOUSE, DEPENDENT)	
CARDHOLDER ID #	GROUP #	CLIENT’S ID # (IF DIFFERENT THAN CARDHOLDER)	
PHYSICIAN INFORMATION	
NAME	TELEPHONE #	
ADDRESS (STREET, CITY, STATE, ZIP CODE)	
ADDITIONAL MEDICATIONS BEING TAKEN	DRUG ALLERGIES	
		
TOTAL DURATION OF THERAPY  	MONTHS	
MEDICATION ORDER	
ITEM	RX NUMBER	ITEM	RX NUMBER	

				
				
PERSON COMPLETING FORM	
NAME	TELEPHONE #	
ATTACH COPIES OF PRESCRIPTION IF AVAILABLE	

FAX FORM TO:   660-886-2121
OR MAIL TO:	RED CROSS PHARMACY
161 SOUTH BENTON
MARSHALL, MO 65340	PLEASE PLACE COPY OF INSURANCE CARD HERE

MO 580-1191 (3-12)	TBC-8 (3-12)