Provider/Partner

Providers

Enrollment Forms

Quickly download the forms you need, then choose from three simple options for sending us a specialty prescription:

  • eScribe to Giant Eagle Specialty Pharmacy or to one of our retail pharmacies
  • Fax an enrollment form to 1-877-645-4142

Please allow for a 24-48 hour turn around time for all prescriptions.

Enrollment forms must be completed and faxed by prescribing practitioners only.

Blood Modifier Enrollment Form

Cosentyx

Crohn’s Disease & Ulcerative Colitis Enrollment Form
OH

Cystic Fibrosis Enrollment Form

Dermatology Enrollment Form

General Enrollment Form

Hepatitis C Enrollment Form

IVIG Enrollment Form

Lupron Enrollment Form

Multiple Sclerosis Enrollment Form

Oncology Enrollment Form

Osteoarthritis Enrollment Form

Osteoporosis Enrollment Form

Rheumatology Enrollment Form A-E

Rheumatology Enrollment Form F-Q

Rheumatology Enrollment Form R-S

Rheumatology Enrollment Form T-Z

Sublocade 100MG Enrollment Form

Sublocade 300MG Enrollment Form

Wound Care

URAC Accredited

Accreditation by URAC demonstrates an organization's commitment to quality and accountability. URAC, an independent, nonprofit organization.

Accreditation by URAC reflects an organization’s dedication and commitment.

ACHC

Accreditation by ACHC reflects an organization’s dedication and commitment to meeting standards that facilitate a higher level of performance and patient care. ACHC, not-for-profit organization since 1986.

Accreditation by ACHC reflects an organization’s dedication and commitment.