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EPCS Down Time Tracking Form
If you believe that a prescriber does not have an EPCS system or the prescriber’s system has been down for an extended period of time, please fill out this form.
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Email
*
Your email
PHARMACY DETAILS
Pharmacy Name:
*
Your answer
Pharmacy Address:
*
Your answer
Pharmacy Phone Number:
*
Your answer
Your Name:
*
Your answer
PRESCRIPTION DETAILS
Prescriber First Name
*
Your answer
Prescriber Last Name
*
Your answer
Prescriber License Type
*
Choose
MD
DO
PA
OD
NP
DDS
DMD
NMD
DPM
Name of Practice
*
Your answer
Practice Phone Number
*
Your answer
Practice Address
*
Your answer
NPI of Prescriber
*
Your answer
Approximate Number of Days System Has Been Down
*
Your answer
Written Date(s) of RX(s)
*
Your answer
RX Number(s)
*
Your answer
Comments:
Your answer
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