How to Submit a Referral
Digital Submission
1
Fill all necessary fields directly in Docusign
2
Attach all additional documentation from the checklist on page 2
3
Add the Provider’s e-signature to the
order by:
a. Signing while filling the form, or
b. Selecting “Finish Later”, then entering the provider’s email to sign and complete the order remotely.
c. Click “Finish” to submit form to Pure.
Email Submission
1
Fill all necessary fields by:
a. Typing directly into the order form, then download or print.
b. Download or print the order form from Docusign and fill by hand.
2
Attach all additional documentation
from the checklist on page 2 and
Provider's signature
3
Email all documents to [email protected]
Fax Submission
1
Fill all necessary fields by:
a. Typing directly into the order form, then download or print.
b. Download or print the order from from Docusign and fill by hand.
2
Attach all additional documentation
from the checklist on page 2 and
Provider's signature
3
Fax all documents to 1-801-931-2631
Select the Appropriate Order Form Below
Please attach all the required insurance information, clinical notes, and labs.
Specialty Pharmacy
Need help with your referral?
Visit our Locations page to find the clinic you’d like to connect with, then call to speak directly with a local Patient Access Coordinator (PAC). Prefer additional support? Click Talk to a Rep to connect with the Specialty Market Executive for your region.
Talk to a Rep