HCP | PANO Service Request Form

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