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Orsini Specialty Pharmacy

Prescribe a Therapy

Find an Enrollment Form

Send a Prescription Directly to Orsini

Where to Send

• E-Prescribe to Orsini Pharmaceutical Services (NPI# 1073608998)
• Call us at 1-800-410-8575, or use the Therapy Care Team numbers listed below
• Fax the enrollment form to us at 1-847-879-9551

How to Send

1. Search below using the medication name, condition, or manufacturer to locate the correct enrollment form
2. Download and print the enrollment form.
3. Complete the form and verify that all information in the enrollment checklist is included.
4. Fax the completed form, signed by the prescriber, to the fax number on the form.

What Happens Next?

• Once an enrollment form is received, our care team will process the prescription and communicate with your office and the patient throughout the benefits investigation, prior authorization, and financial assistance processes.
• Have questions? Call the Therapy Care Team phone number listed below to reach a member of our care team.

Not a Licensed Prescriber? Please note that the enrollment forms below are for licensed prescribers only.  If you are not a licensed prescriber, you can enroll in one of our programs by completing a Patient Enrollment Form.

Find A Medication

Use our search tool to find the medication and form needed.

Enrollment Checklist

It’s best for us to receive all the information we need with each new prescription so that patients can get their care as soon as possible. Help everything run more smoothly by providing this essential information from the start:

• Prescription and start date
• Diagnosis code
• Dosing instructions (total dose, quantity, frequency, and refills)
• Copy of patient insurance card (front and back)
• Patient height, weight, and date of birth
• Patient / caregiver contact information (phone, mobile phone, email)
• Patient medical records supporting treatment (laboratory reports, treatment history, etc.)
• Office point of contact
• Preferred method of contact
• Shipping address for medication delivery