Compliance Meds

Thank You for Contacting Us!

You will receive a call from the number below to discuss your medications within 1 business day of providing your information. We appreciate your patience.

PATIENT FIRST AND LAST NAME

PATIENT GENDER AT BIRTH

FEMALE MALE

CARDHOLDER NAME AND CARDHOLDER DATE OF BIRTH, IF PATIENT IS NOT CARDHOLDER

WHICH EMPLOYER PROVIDES YOUR HEALTH PLAN

HEALTH INSURANCE CARDHOLDER ID NUMBER

DOES PATIENT HAVE ANY OTHER DRUG COVERAGE (SUCH AS MEDICAID, SECONDARY COVERAGE, ETC)? IF YES, PROVIDE DETAILS.

LIST ALL PATIENT DRUG ALLERGIES (FIELD REQUIRED. LIST "NONE" FOR NO DRUG ALLERGIES)

PATIENT DATE OF BIRTH (MMDDYYYY)

PATIENT CELL PHONE NUMBER

PATIENT PERSONAL EMAIL ADDRESS (DO NOT SEND WORK EMAIL ADDRESSES. THEY ARE OFTEN BLOCKED)

THIS FIELD CANNOT BE BLANK. If the patient does not have an email, use HASNOEMAIL@EMAIL.COM as the address. If applicable, documents will come to you from perry.prather@compliancemeds.com. Be sure to check your spam/junk folders. Your documents should arrive within 7 days. If not, check with our office.

PATIENT MAILING ADDRESS

CITY

STATE

ZIP CODE

Check this box ONLY if you are the PATIENT or CARDHOLDER

If the Above Box is UNCHECKED, LIST YOUR NAME & EMAIL HERE

MEDICATION(S) PRESCRIBED (PLEASE INCLUDE STRENGTH, DOSAGE INSTRUCTIONS & TIME OF DAY)

DOCTOR(PRESCRIBER) NAME (First and Last) FOR THE DRUG(S) ABOVE

DOCTOR(PRESCRIBER) PHONE NUMBER FOR THE DRUG(S) ABOVE

If you have had this/these Rx(s) filled previously, please upload a clear image of the full Rx label of your most recent fill here. You may upload it/them later at https://www.hushforms.com/docs

Add file

Please upload a file

By submitting this form, you authorize us to contact your medical provider or pharmacy to obtain any needed prescription records.

I authorize Holmes Pharmacy to provide treatment and service to myself and/or the above-named patient. I also authorize the release of all necessary information to my insurance carrier(s) for direct processing to Holmes Pharmacy. The Health Insurance Portability Accountability Act of 1996 (HIPPA) for Holmes Pharmacy is available upon request. I have reviewed the Notice of Privacy Practices, and I understand that my medical record and other health information with any medical office where I am currently under their care will be shared with Holmes Pharmacy. In writing, I will notify Holmes Pharmacy of specific people who may not be allowed access to any personal health information.

THANK YOU FOR YOUR ENROLLMENT!

By clicking submit you are allowing Holmes Pharmacy to fill, and ship a 90-day supply of your medications.

PLEASE CLICK "SUBMIT" AT THE BOTTOM OF THIS FORM TO SUBMIT THIS FORM FOR PROCESSING.

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Compliance Meds

Thank You for Contacting Us!

Thank You for Contacting Us!

Compliance Meds Team