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.
Email *
PHARMACY DETAILS
Pharmacy Name: *
Pharmacy Address: *
Pharmacy Phone Number: *
Your Name: *
PRESCRIPTION DETAILS
Prescriber First Name *
Prescriber Last Name *
Prescriber License Type *
Name of Practice *
Practice Phone Number *
Practice Address *
NPI of Prescriber *
Approximate Number of Days System Has Been Down *
Written Date(s) of RX(s) *
RX Number(s) *
Comments:
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