Prescription Referral Forms


These interactive forms make sending prescriptions to Avella an easy process. Simply download the form, type or print the appropriate information and fax to Avella. We encourage you to e-prescribe to make the process even easier. 

Contact your account manager for pre-printed forms for your local pharmacy.

This section is for prescribing practitioners only. Patients must bring an original prescription to the pharmacy, and cannot fax these referral forms to Avella. Faxed prescriptions will only be accepted from a prescribing practitioner.

For best results, download the latest version of Acrobat Reader.

Other Referral Forms

Need a form that isn't filled out for a specific disease state, or want to create your own custom form? Do you need to order wholesale from Avella? We have referral forms for that too.

Alternate Form (no specific disease state)

pdf  Alternate referral form

Financial Assistance

pdf  Financial Assistance form

Once we receive the completed referral form Avella staff will:

  • Verify insurance coverage (including co-pays) and files the claim with the insurance carrier.

  • Provide prior authorization (PA) and financial assistance (FA) support to ensure patient access.

  • Physician and patient are notified of the status of the prescription within 48 hours of receipt.

  • Avella will contact the patient to coordinate delivery of the medication and to review their support services during the course of therapy.
  • After medication is received, an Avella pharmacy will discuss with the patient their medication(s), anticipated side effects and how to contact the pharmacy with any questions.

  • Avella's specialty care coordinators will be a partner for the patient throughout the course of therapy to maintain adherence, monitor and report side effects, and ensure patient access to available resources.

Contact an Avella sales representative.