Pharmacy Plan Member Enrollment

Need Assistance? EMAIL help@engedirx.com or CALL 800-663-8029

PLEASE FILL OUT THE FORM BELOW

Employee's EMPLOYER

EMPLOYEE'S NAME

PATIENT FULL NAME

DATE OF BIRTH

MEMBER ID # (if available)

LAST 4 NUMBERS OF S.S. #

CELL OR BEST PHONE NUMBER

HOME PHONE

WORK PHONE (Include EXT)

EMAIL ADDRESS (personal email address preferred)

STREET ADDRESS

CITY

STATE

ZIP CODE

Current Pharmacy

Pharmacy Phone Number

NAME OF MEDICATION, DOSE AND INDICATION (Reason for medication...ex...diabetes)

MEDICATION

DOSE

INDICATION

MEDICATION

DOSE

INDICATION

MEDICATION

DOSE

INDICATION

MEDICATION

DOSE

INDICATION

MEDICATION

DOSE

INDICATION

LIST ANY OTHER MEDICATIONS, DOSE AND INDICATION

FOR MEDICATIONS AVAILABLE THROUGH PERSONAL IMPORTATION*...(Diabetes, HIV, COPD, Depression and Cardiovascular medications), please upload a prescription. WE NORMALLY PROVIDE A 3 MONTH SUPPLY OF THE MEDICATION. PLEASE ASK YOUR PROVIDER TO WRITE THE PRESCRIPTION FOR A 3 MONTH SUPPLY OF THE MEDICATION WITH THREE REFILLS. *Personal Importation - Your medication will come from a certified and licensed Canadian pharmacy.

Prescription

Add file

Please upload a file

Prescription

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Please upload a file

Prescription

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Please upload a file

Prescription

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Please upload a file

Prescription

Add file

Please upload a file

Treating Physician for the above medication(s)

Physician phone number

Physician Address

ALLERGIES

YES NO

IF YES, PLEASE SPECIFY

AUTHORIZATION - IF THE PATIENT IS A DEPENDENT CHILD UNDER THE AGE OF 18

I confirm that she/he is being monitored by a a U.S. physician. I certify that the information provided regarding the dependent is accurate and true.

Checkbox

PARENT OR GUARDIAN'S FULL NAME

UPLOAD A COPY OF PARENT OR GUARDIAN PHOTO ID

Add file

Please upload a file

UPLOAD A COPY OF THE PLAN MEMBER'S PHARMACY/INSURANCE CARD (FRONT AND BACK)

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Please upload a file

AUTHORIZATION - IF THE PATIENT IS THE EMPLOYEE, SPOUSE OR A DEPENDENT CHILD AGE 18 OR OLDER

I certify that the information provided by me is accurate and true.

Checkbox

PATIENT'S FULL NAME

UPLOAD A COPY OF YOUR PHOTO ID

Add file

Please upload a file

UPLOAD A COPY OF THE PLAN MEMBER'S PHARMACY/INSURANCE CARD (FRONT AND BACK)

Add file

Please upload a file

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