Third-Party Insurance Prescriptions

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Information Required on Label
Dispensing Date:
Date Rx was Written:
Patient Name: (first & last)
Physician Name: (first & last)
Drug NDC#:
Drug Name:
Generic Name For:
Brand Name of:
Drug Strength:
Drug Dosage Form:
Drug Manufacturer:
Quantity Dispensed:
Refills:
Beyond-Use Date:
Sig: (Note: start with capital letter, end with period. Do not use ALL CAPS.)	Take 1 tablet by mouth once daily.
Custom Aux Sticker 1:
Auxiliary Label #1	Click Here To Find Aux Label
Auxiliary Label #2	Click Here To Find Aux Label
Auxiliary Label #3	Click Here To Find Aux Label
Auxiliary Label #4	Click Here To Find Aux Label
Medication Bottle Used To Fill Rx
Drug Bottle #:	Click Here To Find Bottle Number
Insurance Billing Information
Insurance Code:
Member Name:
Member ID:
Person Code:
Gender:
Rx BIN:
Rx PCN:
Rx Group:
Prescription Origin Code:
Days Supply:
Pharmacy DAW Code:
Dispensing Documentation
Rx Number:
Date of Dispensing:
RPh Initials:

Original Prescription

 at 0:51, eRx #:82428

ELECTRONIC PRESCRIPTION

Edward M. Miller

432 Locust

Date: 3/8/20XX

Benicar 40 mg Tablet

Dispense 30

Sig: 1 PO QD

Refills: 3

Dr.

DAW: dispense as written

Pharmacist Notes: 

Patient Profile

Name: Miller, Edward M.

Address: 432 Locust

Age: 40

Gender: M

Chronic Illness:

Allergies: Aspirin

OTC Drugs: Tylenol

Doctor Information

Name:

Practice:

Address:

DEA Number:

DAW Codes

DAW 0 - NO DISPENSE AS WRITTEN
(substitution allowed or no generic on market)

DAW 1 - PHYSICIAN writes DISPENSE AS WRITTEN

DAW 2 - PATIENT REQUESTED BRAND

DAW 3 - PHARMACIST SELECTED BRAND

DAW 4 - GENERIC NOT IN STOCK

DAW 5 - BRAND DISPENSED, PRICED AS GENERIC

DAW 6 - OVERRIDE

DAW 7 - SUBSTITUTION NOT ALLOWED BY LAW

DAW 8 - GENERIC NOT AVAILABLE

DAW 9 - OTHER

Insurance Card

United Blue Expressmark
Prescription Drug Card

Member Name:  Edward M. Miller
Member ID:  954706678
Person Code:  00 Edward M., 01 Judy J., 02 Jim S., 03 Jill J.
RxBIN:  337756
RxPCN:  NVEMWJ
RxGROUP:  MYKUWFH2