You may use this form or have your healthcare provider use his/her own script pad.
Print out this form and complete the top portion. Have your Health Care Provider (Medical Doctor, Chiropractor, Dentist, Podiatrist, Nurse Practitioner, Physicians Assistant, Ph.D., Physical Therapist, Doctor of Acupuncture or Doctor of Osteopathy) complete the bottom portion, sign it and mail or fax it in today.
