Online Prescription Request Form

Employee Information
Employee Name* 
Address 
City  State  Zip 
If an address is entered, is this a temporary or permanent change?  Temporary     Permanent
Email 
Daytime Phone*  e.g., 800-555-1212
Cardholder Id # *  Date  e.g., 12/26/2004
Prescription Information
Number of Rx's to be refilled 
This form is for authorized refills of prescription(s) in our files. Please list the Rx numbers, medication name, patient's name and date of birth below. The first row must be filled in completely; the remaining rows are optional.
Rx # Medication Name Days Supply Patient Name Patient DOB , e.g., 05/25/1984
1* This row required*
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Please check if you DO NOT want generic medications. (Refusal of generics may impact your copay.)         Check here for easy open caps.

Billing Information

Total amount of co-payment(s) $

Please charge the credit card you have on file for me.       

Please call me at to obtain payment information.

Please use the space below to add comments or additional information:

Certification Statement

IMPORTANT:I certify that the patient information entered on this form is correct and that the patient named is eligible for benefits under the Prescription Drug Program. I hereby assign to the provider pharmacy any payment due pursuant to this transaction and authorize payment directly to the provider pharmacy. I also authorize release of all information pertaining to the claim to the plan administrator, underwriter, sponsor, policyholder and employer. I have read the CERTIFICATION STATEMENT and hereby certify to and accept the terms thereof.

I accept

 
*Required Fields