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.

Addiction Recovery Enrollment Form

Anemia Recovery Enrollment Form

Crohn's & UC Enrollment Form

Cystic Fibrosis Enrollment Form

Dermatology Enrollment Form

Dupixent Enrollment Form

General Enrollment Form

Hepatitis C Enrollment Form

Mental Health Enrollment Form

Multiple Sclerosis Enrollment Form

Neutropenia Enrollment Form

Osteoarthritis Enrollment Form

Osteoporosis Enrollment Form

Rheumatology Enrollment Form A-L

Rheumatology Enrollment Form M-R

Rheumatology Enrollment Form S-Z

Santyl Enrollment Form

Spravato 56MG Enrollment Form

Spravato 84MG Enrollment Form

Sublocade 100MG Enrollment Form

Sublocade 300MG Enrollment Form

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.