VeracityRx Enrollment Form

Please complete the following information. You will receive a follow-up email from a VeracityRx Associate within 24-48 business hours to discuss your case.

Patient Information Profile

Patient First & Last name

Employer of Insured

Primary Insured First & Last name (if different from above)

Please provide details of your primary drug insurance such as your Policy ID #, Bin #, and Group#. Or, if you prefer, you can upload a copy of your card located at the bottom of this form.

If you have a current manufacturer copay assistance card, please provide a copy. You can upload a copy at the bottom of this form.

Does the Patient have any other drug coverage (i.e., Medicaid, secondary coverage)?

Are you in a high deductible healthcare plan with a Health Savings Account (HSA)?

Yes No

Patient Date of Birth (MMDDYYYY)

Cell Phone Number

10 digits only

Home Phone Number

10 digits only

Patient Personal Email Address (Please be aware that work email addresses could be blocked)

Patient Mailing Address

City

State

Zip Code

Below are two separate drug lists. Please review both lists and select the drug(s) you are currently prescribed. If your drug(s) are not present on either list, please select "Other" and provide the name of each prescription medication not listed.

If you selected "Other", please provide the drug name.

If you chose a "Specialty" drug, please provide income range and household size below.

Please include the strength of the drug(s) you are prescribed.

This drug(s) is used to treat what condition?

List any Allergic Reaction you may have had and the name of the drug which caused the reaction.

Doctor (prescriber) name for the drug(s) above

Doctor (prescriber) phone number for the drug(s) listed above

10 digits only

Doctor (prescriber) "fax" number for the drug(s) listed above

10 digits only

Please list any other drugs you are currently taking

Please check box to grant permission to contact the prescriber on your behalf regarding your medication(s).

Please check the box to confirm.

Is Patient a Smoker or Non-Smoker?

Non-Smoker Smoker

Are you allergic to Latex?

Yes No

Are you a Veteran?

Yes No

If you are enrolling to receive your medication(s) through the personal importation program, please confirm that you understand the medication(s) will be fulfilled from a Canadian pharmacy, and you authorize this shipment from Canada.

Please check the box to confirm.

Files

Add file

Please upload a file

Questions? Need help? Email: help@veracity-rx.com

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VeracityRx Enrollment Form

Welcome!

Welcome!