To submit this form, you can send it via fax to the provided number on the form, email it to the specific address mentioned, or mail it to the physical address listed at the bottom. Ensure your contact information is correct to receive confirmation. For online submissions, follow the platform's specific guidelines to upload your form securely.

Keep your eye on any updates or changes in benefit policies for 2024 and 2025. This form may have specific deadlines linked to your health plan enrollment period. Make sure to submit the form promptly for timely processing.

The purpose of this form is to gather essential information from new patients to facilitate home delivery of prescriptions. It ensures that the pharmacy has all the necessary details to fill prescriptions correctly and efficiently. This form plays a crucial role in streamlining the medication management process for patients.

• 1. First Name: The first name of the patient or cardholder.
• 2. Last Name: The last name of the patient or cardholder.
• 3. Date of Birth: The date of birth in MM/DD/YYYY format.
• 4. Gender: The gender of the patient.
• 5. Allergies: List of any known allergies.
• 6. Health Conditions: Document any serious health conditions.
• 7. Doctor/Prescriber Information: Details of the prescribing physician.
• 8. Shipping Address: Complete address for delivering prescriptions.
• 9. Payment Information: Details regarding payment options.

If the form is not submitted correctly, your prescription order may be delayed or rejected. It's crucial to provide complete and accurate information to prevent any issues. Incomplete forms can lead to misunderstandings in your medication dispensing.

• Delay in Processing: Incomplete forms can result in delays in receiving your prescribed medications.
• Incorrect Medication: Missing information may lead to the pharmacy dispensing incorrect medication.
• Loss of Benefits: Failure to submit may result in losing potential benefit coverage for home delivery.

• 1. New Patient Registration: For patients registering for home delivery medications.
• 2. Medication Management: To facilitate easy management of regular prescriptions.
• 3. Family Accounts: For caregivers managing prescriptions for multiple family members.