Pharmacy Referral

Please use this electronic referral form to send new referrals to the Cypress Care Customer Care Team. If you already have a Sequoia login, click here .

Patient Information (* required)

* Client:
* Claim #:
* Last Name:
* First Name:
Gender:
SSN:
* Address:
* Phone:
* City:
* State: Zip:
* Date of Birth: (MM/DD/YYYY)
* Date of Injury: (MM/DD/YYYY)
Employer:
ICD9:

Prescribing Physician

Name:
Address:
City:
State: Zip:
Phone:

Insurance Information

* Adjuster:
Adjuster Email:
* Phone:

Case Manager Info

Name:
Email:
Phone:

Authorized Medications

Pharmacy Info

Pharmacy Name
Phone #

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