Physicians
New Patient Enrollment Form
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Complete the PharmaHealth New Patient Enrollment Form online. |
Download the PharmaHealth New Patient Enrollment Form and fax or mail it back to us. |
Responsible Party Statement |
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Diabetic Shoes: Physician Forms & Prescription
Below you will find all the necessary paperwork required by Medicare to assist your patients in receiving their Diabetic Footwear. Please choose a location, complete the required paperwork and fax/mail it back to us. If you have any questions, please call your selected PharmaHealth location and speak with one of our Certified Shoe Fitters or Pharmacists.
Medicare requires that all patients have the following Phycian Forms completed:
- Doctor Request for Information Letter
- Certificate of Medical Necessity & Statement of Certifying Physician
- Diagnosis of Qualifying Condition Form
- Prescription
PharmaHealth (Hawthorn)
535 Faunce Corner Rd. Dartmouth, MA 02747
Phone: 508-998-7888 Fax: 508-998-9866
Click Here to Download PDF. Forms
PharmaHealth (North End)
2206 Acushnet Ave. New Bedford, MA 02745
Phone: 508-998-1121 Fax: 508-998-1122
Click Here to Download PDF. Forms
PharmaHealth (South End)
458 Dartmouth St. New Bedford, MA 02740
Phone: 508-996-3778 Fax: 508-996-3779
Click
Here to Download PDF. Forms
How To Write A Prescription For A Compounded Medication
Our Compounding Pharmacists will be more
than happy to discuss formulations or answer
any other medication compounding questions
you may have. Please call 508-996-3778 for
more information.
Compounding Lab Info:
458 Dartmouth Street, Suite B
New Bedford, MA 02740
Phone: 1.888.790.7979
Fax: 1.888.584.6337
Email: Compounding@PharmaHealth.us
www.PharmaHealthCompounding.com
