Did you know?
All NJ Rx Pads ordered after May 18
must have the NEW High Security Features.
These NEW Rx PADS must be in use by Aug 18.
Have you ordered your new pads?
Your source for New Jersey Security Rx Pads
ATTENTION: NEW JERSEY PRESCRIPTION PAD USERS
Here are the New Jersey state requirements, as we understand them at this time:
Prescription forms will be required for each practitioner, group practice or institution. The printing on each form must include name, street,
city, state, zip code, telephone number, and the prescriber’s New Jersey professional license/registration number. There is also a space for the
DEA # to be written or stamped on the form. Institutional forms can choose to preprint the institution information and leave a space for the
specific prescriber’s information to be written or stamped. Computer software can print the actual prescriber’s/institution’s name and other
required information.
•
Repetitive Hollow Void Pattern – The word “VOID” must appear in a hollow pattern across the entire face of the
•
Thermochromic “Rx” Ink Feature – The front of the prescription must contain a magenta friction-activated “Rx” symbol
prescription form when it is scanned, photocopied or faxed.
in one location that will disappear or change color when rubbed. It should return to its original color when cooled.
•
NJ State Seal Background – The background void pantograph will also contain a repetitive NJ state seal pattern reversed
out of the green background.
•
•
Security Back Print – The back of the prescription must include a box listing all of the security features.
Unique ID & Barcode – A unique 15 digit identifier number and matching barcode must be printed on each form. No two
forms may have the same ID number.
•
Microprinting – A line of micoprinted type appears on the face of each NJPB under the words PRESCRIPTION BLANK.
TO ORDER YOUR NEW NJPB (New Jersey Prescription Blanks) contact us at:
19 Sheridan Ave., Ho-Ho-Kus, NJ 07423
201-444-0236 • 201-445-6660
[email protected]
hohokus.minutemanpress.com
Minuteman Press
19 Sheridan Avenue | Phone: 201.444.0236
Ho-Ho-Kus, NJ 07423 | Fax: 201.445.6660
Rx Pad Forms
IMPORTANT: Please return all four (4) forms with options you have chosen circled.
Please make photocopies of this form and keep it on hand and use for future orders.
Thank you.
For #1: Doctors – MD, DO, DDS, DMD, DPM, DVM
Number of
pads
NJ 1-Part
No back print
NJ 2-Part
Without printing
NJ 2-Part
With printing – per pad
5 pads
10 pads
20 pads
40 pads
60 pads
80 pads
120 pads
240 pads
480 pads
$111.00
$130.00
$196.00
$288.00
$390.00
$496.00
$708.00
$1104.00
$1920.00
$152.50
$179.00
$274.00
$408.00
$600.00
$760.00
$1104.00
$1824.00
$2976.00
+ $5.80
+ $3.40
+ $2.90
+ $2.70
+ $2.70
+ $2.70
+ $2.60
+ $2.60
+ $2.60
There will be an additional $20.00 per proof, if requested.
**Price list does NOT include shipping charges**
New Jersey State Rules:

Black ink ONLY & start number must always be 0001.

For back printing, please reference column #4 above for additional charges.

Please indicate on your order if you would like front printing on the second
portion of 2-part forms. All 2-part forms will be blank on second page unless
otherwise specified. If this is not indicated in the order, we can only re-print
at further cost.

Only one nurse or physician assistant is permitted per pad with collaborating
physician. Please refer to page four (4) for templates and choices.
Minuteman Press Rules:

To avoid errors in processing, please print as clear as possible.

Minuteman Press will NOT be responsible for errors related to handwriting if no
proof is requested. NO EXCEPTIONS.
1
Minuteman Press
19 Sheridan Avenue | Phone: 201.444.0236
Ho-Ho-Kus, NJ 07423 | Fax: 201.445.6660
Address
City
State
Zip
Quantity
If Reorder – Previous Job #
Signature
Style
#1
#2
#3
#4
#5
#6
#7
#8
MD, DO, DDS, DMD, DPM, DVM
Health Care Facility
Optometrist TPA Certified
Nurse Practitioner / Clinical Nurse
Certified Nurse Midwife
Prescribing Eye Wear
Combo Eye Wear / TPA Certified
Physician Assistant
PC41-NJ 1-Part
PC41-NJ 1-Part
PC41-NJ 1-Part
PC41-NJ 1-Part
PC41-NJ 1-Part
PC41-NJ 1-Part
PC41-NJ 1-Part
PC41-NJ 1-Part
Practice Name
PC41-NJ 2-Part
PC41-NJ 2-Part
PC41-NJ 2-Part
PC41-NJ 2-Part
PC41-NJ 2-Part
PC41-NJ 2-Part
PC41-NJ 2-Part
PC41-NJ 2-Part
Physician Name
Specialty
Address (No P.O. Box Allowed)
City
State
Phone
Fax (optional)
DEA #
License #
Certification # (only required on Format #3 & #7)
Zip
NPI #
Serial #000001 (Required – Each order will start with #000001). COMPLETE
INFORMATION REQUIRED BEFORE RETURNING FORMS.
2
Minuteman Press
19 Sheridan Avenue | Phone: 201.444.0236
Ho-Ho-Kus, NJ | Fax: 201.445.6660
Additional Doctors and Nurse Information
From this point on, you can have up to four (4) doctors on one pad. Pads with nurse
and/or physician assistant can only have one individual per pad. All orders MUST
follow templates and guidelines by state law.
Shipping Information: Official address on file with the State Board
Address
City
State
Zip
IMPORTANT NOTICE: If more than one prescriber is listed on the same blank, one of
the prescribers is to be responsible for the shipment. That person must sign here:
PLEASE NOTE: By signing, you agree that you are the responsible party for this shipment of
prescription blanks. Please make certain that the address given above is the same as it appears with
your medical licensing board.
Prescriber Signature **Needed each time an order is placed**
Optional - Additional doctors to be printed on the same prescription blank (or one
collaborating physician if ordering pads for Nurse Practitioner/Certified Nurse
Midwife/Physician Assistant):
1.
2.
Prescriber Name
Prescriber Name
License #
Degree
License #
Degree
DEA # or other info to be printed
DEA # or other info to be printed
Prescriber Signature
Prescriber Signature
3.
4.
Prescriber Name
Prescriber Name
License #
Degree
License #
Degree
DEA # or other info to be printed
DEA # or other info to be printed
Prescriber Signature
Prescriber Signature
3
For #2 - #8: All Other Formats
Number of pads
NJ 1-Part
No back print
NJ 2-Part
Without printing
NJ 2-Part
With printing – per pad
5 pads
$113.50
$167.50
+ $5.80
10 pads
$140.00
$214.00
+ $3.40
20 pads
40 pads
60 pads
80 pads
120 pads
$226.00
$352.00
$492.00
$640.00
$924.00
$360.00
$616.00
$894.00
$1160.00
$1668.00
+ $2.90
+ $2.70
+ $2.70
+ $2.70
+ $2.60
240 pads
$1488.00
$2928.00
+ $2.60
480 pads
$2592.00
$4848.00
+ $2.60
4