New Patient Enrollment

New Patient Registration

Welcome to ahma Rx! Please provide the below information so we can get you your prescription as quickly as possible. Thanks!
Form Name
Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
E-mail
Please enter to receive tracking information for your rx delivery.
Cellphone Number:
Please note we will be sending you updates of status and deliveryFormat: (000) 000-0000.
Home Phone Number:
Format: (000) 000-0000.
Do you have any drug allergies?
Please list any drug allergies:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you want your medication delivered to your home address?
Delivery Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the delivery address a doorman building?
Can the package be left at the doorstep/porch if no one is home?
Which location will you pick up from?
Emergency Contact Opt-Out
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have prescription insurance coverage?
Please Take a Photo of the Front and Back of your Prescription Insurance Card (We will need the RX BIN, PCN, GRP, and ID.)
Take a Photo of the Front of Your Prescription (Rx) Insurance Card
Take a Photo of the Back of Your Prescription (Rx) Insurance Card
If you are unable to provide a photo of your insurance card, please provide the following:
RX BIN
RX PCN
RX ID NUMBER
RX GRP
I appoint ahma Rx to act as my representative in connection with any claim or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize ahma Rx to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim(s), appeal(s), grievance(s) or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to ahma Rx and that ahma Rx will not charge additional fees, beyond any copayments as dictated by my insurance, to be my representative.
Signature (Drag Finger or Mouse to Sign)
Date

MonthDayYear
Date
Thanks for submitting your info! We will reach out to you shortly. Please expect a text message or call from us. If you have any questions, you can call/text us as 212-749-6626.
Should be Empty:

New Patient Registration