Pharmacist Concierge Services Enrollment Form

Thank You for Contacting Us!

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.

PATIENT FIRST & LAST NAME

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.

PATIENT GENDER AT BIRTH

Male Female

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

WHICH EMPLOYER PROVIDES YOUR HEALTH PLAN:

(Type "SELF PAY" above if you are a self-paying individual.)

HEALTH INSURANCE CARDHOLDER ID NUMBER

This is the ID number found on your health insurance card

USE THIS AREA TO PROVIDE THE DETAILS OF WHAT ORGANIZATION REFERRED YOU TO US, IF YOU WERE REFERRED. PLEASE LIST "NONE" IF THERE WAS NO DIRECT REFERRAL.

DOES PATIENT HAVE ANY OTHER PRESCRIPTION DRUG COVERAGE (SUCH AS MEDICAID, MEDICARE PART D, SECONDARY COVERAGE THRU ANOTHER EMPLOYER, ETC)? IF YES, PROVIDE DETAILS.

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

IS THE PATIENT ALLERGIC TO LATEX?

YES

PATIENT SMOKER STATUS?

NON-SMOKER

SMOKER

PATIENT IS A UNITED STATES VETERAN?

YES

PATIENT DATE OF BIRTH (MMDDYYYY)

PATIENT CELL PHONE NUMBER

10 digits only, no parentheses or dashes

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 pharmacist@helpmewithmyrx.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

SPECIALTY DRUG(S) PRESCRIBED (PLEASE INCLUDE STRENGTH & DOSAGE INSTRUCTIONS)

THIS DRUG IS TO TREAT WHAT CONDITION?

USE THIS AREA TO PROVIDE ANY ADDITIONAL MEDICATION INFO:

ESPECIALLY THE DETAILS IF THIS DRUG IS REPLACING SOME OTHER MEDICATION YOU HAVE BEEN TAKING

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

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

Please check box to grant permission for Pharmacist Concierge Services to contact the prescriber on your behalf regarding your medication(s)

If you have had this/these Rx(s) filled previously, please upload a clear image of the FULL (both sides or either peel it away enough to get all in one image) Rx label of your most recent fill here. Need to make sure your name, pharmacy info, doctor info, qty dispensed, and number of refills shows on the image(s) you send. You may upload it/them later at https://www.hushforms.com/docs

Add file

Please upload a file

THANK YOU FOR YOUR ENROLLMENT!

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

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Pharmacist Concierge Services Enrollment Form

Thank You for Contacting Us!

Thank You for Contacting Us!

Pharmacist Concierge Services Team