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HCP | PANO Service Request Form
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Step 1 - Patient Form: Confirm your patient has submitted the patient Service Request Form half
  • Has your patient completed his or her half of the Service Request Form? If not, he or she can complete it here.
  • The patient Service Request Form half can be completed multiple times and PANO will use the latest submission.
  • Patient's confirmation number is required for Step 2 below.

Step 2 - HCP Form: Fill out the HCP Service Request Form half
  • The patient's confirmation number will be required to continue the process.
  • If your patient is unable to provide the confirmation number , you can contact PANO at 1-800-282-7630 for assistance.
  • After submitting the form, fax your prescription to PANO at 1-888-891-4924.

Or download a form to print and fax: Print and Fax Form

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