State-regulated prescription pads. State-regulated prescription pads CALIFORNIA PRESCA1BL PRESCA2BLM FORM # PRESCA1BL W x 41 4 H.
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3 Delaware CALIFORNIA PRESCABL PRESCABLM PRESCABL PRESCABLM 5 W x 4 4 H 5 W x 4 4 H PRESCABL PRESCABLM 5 W x 4 4 H 5 W x 4 4 H PRESDEBLH PRESDEBLVNO Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue Background, California Security Prescription Watermark on Back, Preprinted Prescriber Information, Batch & Sequential Numbering, Thermochromic Ink, License and DEA Numbers, Reverse, Microprinting in Line, Format & Requirements, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid & Controlled Substance Approved! Must order in multiples of 8 for sequential numbering. PRESDEBLH PRESDEBLV 5 W x 4 4 H 4 PRESDEBLHNO PRESDEBLVNO 5 W x 4 4 H 4 Security Features: Chemical Void Paper, Scallop Void Pantograph, Blue Background, Delaware Security Prescription Watermark on Back, Preprinted Prescriber Information, Consecutive Numbering, Thermochromic Ink, Microprinting in Line, Security Feature Listing, Watermark in Coin Reactive Ink. 3
4 Name Interchange is mandated unless the practitioner indicates "NO SUBSTITUTION" in accordance with the law. BLUE BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK. Age Name Interchange is mandated unless the practitioner indicates "NO SUBSTITUTION" in accordance with the law. GREEN BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK. Age Name Interchange is mandated unless the practitioner indicates "NO SUBSTITUTION" in accordance with the law. BLUE BACKGROUND. SECURITY FEATURES LISTED ON BACK Age FLORIDA PRESBLH PRESGNH PRESBLV PRESINBL INDIANA Security Features: Chemical Protection Paper, Scallop Void Pantograph, Reflex Blue Background, Indiana Security Prescription Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Reverse Symbol, Format & Requirements, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid & Controlled Substance Approved! PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 4 H PRESGNV 4 4 W x 5 4 H PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 H PRESGNV 4 4 W x 5 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue or Green Background, Security Prescription Watermark on Back, Preprinted Prescriber Information, WIL Batch Numbering, Thermochromic Ink, Microprinting in Border Line, License Number, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid & Controlled Substance Approved! PRESINBL 5 W x 4 4 H PRESINBL 5 W x 4 4 H PRESKYGN KentuCKy Security Features: Chemical Protection Paper, Scallop Void Pantograph, Pantone Green Background, Kentucky Security Prescription Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Reverse Symbol, Format & Requirements, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid & Controlled Substance Approved! PRESKYGN 5 W x 4 4 H PRESKYGN 5 W x 4 4 H MAINe MASSACHUSettSS 3 Physicians Way Anytown, U.S.A Physicians Way Anytown, U.S.A Physicians Way Anytown, U.S.A. 345 PRESGNH PRESBLH PRESBLH PRESGNH PRESBLV PRESGNH 5 W x 4 4 H PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLH 5 W x 4 4 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Green or Blue Background, Security Prescription Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Format & Requirements, Security Feature Listing, Watermark in Coin Reactive Ink. PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 4 H PRESGNV 4 4 W x 5 4 H PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 H PRESGNV 4 4 W x 5 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue or Green Background, Security Prescription Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid & Controlled Substance Approved! PP
5 NEW JERSEY State of New Jersey PRESCRIPTION BLANK S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S E Y P R E S C R I P T I O N B L A N K S T A T E O F N E W J E R S EY P R E S C R I P T I O N B L A N K PRINT: CNM PA PRT NAME, DEGREE (SUPERVISING PHYSICIAN) CITY, STATE ZIP (000) : D PRESCRIBER E A SPD # COLLABORATIVE PHYS: PRESnjhcfV PATIENT D.O.B. DATE PRESnjmdV PRESnjmwV SUBSTITUTION PERMISSIBLE PRESnjoptV PRESnjpaV NOT VALID FOR CONTROLLED SUBSTANCES IF ISSUED BY AN OPTOMETRIST NAME OF PROFESSIONAL PRACTICE TELE # CERT# APN LICENSE / CERTIFICATE / AUTHORIZATION # PRESnjeyeV NAME AND TITLE OF PHYSICIAN ASSISTANT CHECK IF: PHYSICIAN NAME NAME AND TITLE OF PRESCRIBER AND, IF APPLICABLE, COLLABORATIVE PHYSICIAN LICENSE # PRESnjapnV NAME, DEGREE, TITLE DO NOT SUBSTITUTE SIGNATURE OF PRESCRIBER DO NOT REFILL REFILL TIMES Use a separate form for each controlled substance prescription THEFT, UNAUTHORIZED POSSESSION AND/OR USE OF THIS FORM INCLUDING ALTERATIONS OR FORGERY, ARE CRIMES PUNISHABLE BY LAW PRESNJAPNV PRESNJEYEV PRESNJHCFV PRESNJMDV PRESNJMWV PRESNJOPTV PRESNJPAV PRESNJAPNV PRESNJEYEV PRESNJHCFV PRESNJMDV PRESNJMWV PRESNJOPTV PRESNJPAV Security Features: Chemical Protection Paper, Flatscreen Void Pantograph with Hollow Void, Green Background on Front, Blue Background on Back, Preprinted Prescriber Information, 5 Digit Identifier, Barcode, New Jersey State Seal, Thermochromic Ink, Microprinting, Security Feature Listing. Medicaid & Controlled Substance Approved! Must order in multiples of 8 for consecutive numbering. NEW JERSEY Laser rx paper State of New Jersey PRESCRIPTION BLANK NAME, DEGREE, TITLE STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK STATE OF NEW JERSEY PRESCRIPTION BLANK PA PRT SPD DATE NAME, DEGREE (SUPERVISING PHYSICIAN) CITY, STATE ZIP NOT VALID FOR CONTROLLED SUBSTANCES IF ISSUED BY AN OPTOMETRIST SUBSTITUTION PERMISSIBLE DO NOT REFILL NAME OF PROFESSIONAL PRACTICE TELE # CERT# # COLLABORATIVE PHYS: PATIENT D.O.B. NAME AND TITLE OF PHYSICIAN ASSISTANT (000) D PRESCRIBER: E A CNM PHYSICIAN NAME APN LICENSE / CERTIFICATE / AUTHORIZATION # CHECK IF: NAME AND TITLE OF PRESCRIBER AND, IF APPLICABLE, COLLABORATIVE PHYSICIAN LICENSE # PRINT: DO NOT SUBSTITUTE SIGNATURE OF PRESCRIBER REFILL TIMES PRESNJEYELGNI PRESNJAPNLGNI PRESNJHCFLGNI PRESNJMDLGNI Use a separate form for each controlled substance prescription THEFT, UNAUTHORIZED POSSESSION AND/OR USE OF THIS FORM INCLUDING ALTERATIONS OR FORGERY, ARE CRIMES PUNISHABLE BY LAW PRESNJMWLGNI PRESNJOPTLGNI PRESNJPALGNI PRESNJAPNLGNI PRESNJEYELGNI PRESNJHCFLGNI PRESNJMDLGNI PRESNJMWLGNI PRESNJOPTLGNI PRESNJPALGNI - Green Front, Blue Back 500/Pkg Security Features: Chemical Protection Paper, Flatscreen Void Pantograph with Hollow Void, Green Security Background on front, Blue Background on back, Preprinted Prescriber Information, 5 Digit Identifier, Barcode, New Jersey State Seal, Thermochromic Ink, Microprinting, Security Feature Listing. Medicaid & Controlled Substance Approved! We stay apprised of the latest state mandates to ensure our prescription pads are compliant with each state s stringent requirements. 5
6 NAME Patient Name DATE BLUE BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK and over Any drug which is the generic or chemical equivalent of the drug specified above in this prescription may be dispensed provided that the drug dispensed is listed in the current edition of either the National Formulary or the United States Pharmacopoeia and provided that no check mark ( ) has been handwritten in the box in the right-hand lower corner. Prescription is void if more than one () prescription is written per blank. BLUE BACKGROUND. SECURITY FEATURES LISTED ON BACK PATIENT NAME NAME DATE GREEN BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK. Any drug which is the generic or chemical equivalent of the drug specified above in this prescription may be dispensed provided that the drug dispensed is listed in the current edition of either the National Formulary or the United States Pharmacopoeia and provided that no check mark ( ) has been handwritten in the box in the right-hand lower corner. Prescription is void if more than one () prescription is written per blank. GREEN BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK. DATE and over PATIENT NAME Name BLUE BACKGROUND. SECURITY FEATURES LISTED ON BACK Any drug which is the generic or chemical equivalent of the drug specified above in this prescription may be dispensed provided that the drug dispensed is listed in the current edition of either the National Formulary or the United States Pharmacopoeia and provided that no check mark ( ) has been handwritten in the box in the right-hand lower corner. Prescription is void if more than one () prescription is written per blank. BLUE BACKGROUND. REFLECTIVE WATERMARK ON BACK. SECURITY FEATURES LISTED ON BACK. DATE and over PENNSYLVANIA WashingtON 3 Physicians Way Anytown, U.S.A. 345 DEA # 3 Physicians Way Anytown, U.S.A. 345 DEA # 3 Physicians Way Anytown, U.S.A. 345 DEA # PRESBLH PRESGNH PRESBLV PRESWABLH PRESWABLH PRESWABLV SIGNATURE SUBSTITUTION PERMISSIBLE IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST HANDWRITE "BRAND NECESSARY" or "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. SIGNATURE SUBSTITUTION PERMISSIBLE IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST HANDWRITE "BRAND NECESSARY" or "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. SIGNATURE SUBSTITUTION PERMISSIBLE IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST HANDWRITE "BRAND NECESSARY" or "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 4 H PRESGNV 4 4 W x 5 4 H PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 H PRESGNV 4 4 W x 5 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue or Green Background, Security Prescription Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, License Number, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid & Controlled Substance Approved! PP Physicians Way Anytown, U.S.A. 345 PRESBLV Refill NR Void After PP0--05 WyOMING Refill NR Void After 3 Physicians Way Anytown, U.S.A. 345 PRESGNH PP0--05 Refill NR Void After 3 Physicians Way Anytown, U.S.A. 345 PRESBLH PRESWABLH 5 W x 4 4 H PRESWABLV 4 4 W x 5 4 H PRESWABLH 5 W x 4 4 H PRESWABLV 4 4 W x 5 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue Background, Preprinted Prescriber Information, WA Thermochromic Ink, Microprinting in Border Line, Security Feature Listing. PRESWVGN WEST VIRGINIA Security Features: Chemical Protection Paper, Scallop Void Pantograph, Green Background, Security Prescription Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Reverse Symbol, Format & Requirements, Security Feature Listing, Watermark in Coin Reactive Ink. PRESWVGN 5 W x 4 4 H PRESWVGN 5 W x 4 4 H PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 4 H PRESGNV 4 4 W x 5 4 H PRESBLH 5 W x 4 4 H PRESGNH 5 W x 4 4 H PRESBLV 4 4 W x 5 H PRESgnV 4 4 W x 5 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue or Green Background, Security Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Security Feature Listing, Watermark in Coin Reactive Ink. State-Regulated Pads. We stay apprised of the latest state mandates to ensure our prescription pads are compliant with each state s stringent requirements. Upcharges apply: Consecutive Numbering, Sequential Numbering, Proofs, Rush Delivery, Additional Ink Colors, PMS Matching, Chipboard and Special Polywrapping. Prices subject to change without notice. 6
7 Laser Paper CALIFORNIA LASer rx paper DeLAwARe LASer rx paper PRESCABLBLI PRESCAlBLI PRESCASHlBLI PRESDELBLI PRESDELBLI PRESDELBL4I QTY PRESCABLBLI*, PRESCALBLI* - Blue 50/Pkg PRESCAshLBLI - Blue 50/Pkg Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue Background, California Security Prescription Watermark on Back, Preprinted Prescriber Information, Batch & Sequential Numbering, Thermochromic Ink, License and DEA Numbers, Reverse, Microprinting in Line, Security Feature Listing, Watermark in Coin Reactive Ink. PRESDELBL, PRESDELBLI* - Blue PRESDELBL, PRESDELBLI* - Blue, Horizontal Perf PRESDELBL4, PRESDELBL4I* - Blue, Horizontal & Vertical Perf 50/Pkg Security Features: Chemical Void Paper, Scallop Void Pantograph, Blue Background, Delaware Security Prescription Watermark on Back, Consecutive Numbering, Thermochromic Ink, Microprinting in Border Lines, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid Compliant! WASHINGTON LASer rx paper StANDARD LASer rx paper PRESWALBL PRESWALBL PRESWALBL4 PRESLGN PRESlBL PRESLBL4 PRESWALBL - Blue PRESWALBL - Blue, Horizontal Perf PRESWALBL4 - Blue, Horizontal & Vertical Perf 500/Pkg Security Features: Scallop Void Pantograph, Blue Background, WA Thermochromic Seal, Microprinting in Security Feature Listing, Chemical Protection Paper, Line Watermark, Invisible Fluorescent Fibers, Security Feature Listing. Medicaid Compliant! PRESLBL, PRESLBLI* - Blue or Green PRESLGN, PRESLGNI*- PRESLBL, PRESLBLI* - Blue or Green, Horizontal Perf PRESLGN, PRESLGNI*- PRESLBL4, PRESLBL4I* - Blue or Green, Horizontal & PRESLGN4, PRESLBL4I* Vertical Perf 500/Pkg Security Features: Scallop Void Pantograph, Blue or Green Background, Thermochromic Ink, Microprinting in Security Feature Listing, Chemical Protection Paper, Security Watermark, Invisible Fluorescent Fibers, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid Compliant! Count on Us...the best prescription for sales! 7
8 StANDARD-secure blue StANDARD-secure GReen PRESBLH PRESBLV PRESGNH PRESGNV PRESBLH 5 W x 4 4 H PRESBLV 4 4 W x 5 4 H PRESBLH 5 W x 4 4 H PRESBLV 4 4 W x 5 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Blue Background, Security Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid Compliant! PRESGNH 5 W x 4 4 H PRESGNV 4 4 W x 5 4 H PRESGNH 5 W x 4 4 H PRESGNV 4 4 W x 5 H Security Features: Chemical Protection Paper, Scallop Void Pantograph, Green Background, Security Watermark on Back, Preprinted Prescriber Information, Thermochromic Ink, Microprinting in Border Line, Security Feature Listing, Watermark in Coin Reactive Ink. Medicaid Compliant! 4# standard - bond paper PRESWHHBD PRESPNKVBD PRESWHHBD - White 5 W x 4 4 H PRESWHVBD - White 4 4 W x 5 H PRESBLHBD - Blue 5 W x 4 4 H PRESBLVBD - Blue 4 4 W x 5 H PRESCANHBD -Canary 5 W x 4 4 H PRESCANVBD -Canary 4 4 W x 5 H PRESGNHBD - Green 5 W x 4 4 H PRESGNVBD - Green 4 4 W x 5 H PRESPNKHBD - Pink 5 W x 4 4 H PRESPNKVBD - Pink 4 4 W x 5 H Standard Bond Paper Color Options: White, Blue, Green, Pink, Canary Standard-Secure Prescription Pad Features: Convenient, Tamper-Resistant Pocket- Pads and Books -part and -part prescription pads Competitive Leadtime: 3 business days on -part up to 48 pads or -part up to 7 books (black imprint only) Competitive Pricing Smaller Order Quantities Accepted Minimum of 4 pad orders accepted on -part (non-numbered) Minimum of 8 pads orders on -part (numbered) Minimum of 9 book orders accepted on -part Two-Color Logo Available (on non-numbered pads/books upcharges apply) Compliant with the 008 Requirement for Use of Tamper-Resistant Prescription Pads Under the Medicaid Program Multiple Security Features for your customers protection (see page ) StANDARD rx ROLLS Security Features: Flat Screen Void Pantograph, Reverse, Blue Background, Thermochromic Ink, Artificial Watermark, Batch Numbering Security Feature Listing, Watermark in Coin Reactive Ink. Federal-Regulated Pads. We specialize in high technology, state-of-the-art, tamper and fraud-resistant security paper products. Our pads & products are guaranteed compatible with Federal regulations for prescription format and meet or exceed security features. RX SPEC GUIDE 066
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