&WU Langone INCDICAl CI '..H Pharmacy Information
&WU Langone INCDICAl CI '..H Pharmacy Information
With the installation of Epic, the new electronic medical record system, at this practice, your doctor Is now able to e-
prescribe. This means that any prescriptions the doctor may give you today will be automatically routed to the pharmacy
of your choice and we will no longer have to provide you with handwritten prescriptions. In addition, when you run out of
refills on your medication, the pharmacist can now electronically send renewal requests to this office for approval.
**Note: Controlled medications are not eligible for e-prescribing.
Patient Name: Please complete the Information below if you are interested in e-prescribing.
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Preferred Pharmacy
Name of Pharmacy:
Address: City: State: Zip Code:
Phone Number:
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nItivtl \JOCK Alternate Pharmacy
Name of Pharmacy:
Address: City: State: Zip Code:
Phone Number:
Fax Number:
Laboratory Information CO ' -Pu A44\cl
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Please indicate by placing a checkmark next to one of the options below to identify your preferred laboratory. Some
insurance plans require that covered patients utilize specific laboratories; failure to follow their guidelines can lead to bills
that become the patient's responsibility. If you do not know which laboratory to select, please contact your insurance
carrier. If you do not select a laboratory, the practice will default any lab tests to NYU laboratory.
NYU Lab
Other External Location Please provide name of external location:
EFTA00313925