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 address *
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 *
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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