You will receive a call from the number below to discuss your case within 5 business days of providing your information. We appreciate your patience.
Only one form is necessary per individual. If you have more than one drug to list, just provide the info for the additional drugs on this enrollment form.
(Type "SELF PAY" above if you are a self-paying individual.)
This is the ID number found on your health insurance card
10 digits only, no parentheses or dashes
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 firstname.lastname@example.org. Be sure to check your spam/junk folders. Your documents should arrive within 7 days. If not, check with our office.
ESPECIALLY THE DETAILS IF THIS DRUG IS REPLACING SOME OTHER MEDICATION YOU HAVE BEEN TAKING
Please upload a file
THANK YOU FOR YOUR ENROLLMENT!
PLEASE CLICK "SUBMIT" AT THE BOTTOM OF THIS FORM TO SUBMIT THIS FORM FOR PROCESSING.