MedPack Enrollment Form

Simplify My Meds (Med Pack)

Patient Enrollment Form
Name*

First NameLast Name
Gender*
DOB:*

MonthDayYear
Date
Cell Phone number (Text-Enabled):*
Please enter a valid phone number.
Email Address(for receipt/communication):*
example@example.com
Home Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Special Delivery Instructions:*
Require Signiture on delivery?*

YesNo
INSURANCE
Medicaid#
if applicable
Insurance ID#
if applicable
Insurance Group #
Insurance phone#
if applicable
List of current medications, dosage, and when you take them (morning, night, etc.):*
Patient Agreement

We are pleased to welcome you to Simplify My Meds our medication synchronization program.

Advantages of participating in the program include:
- Increased convenience-a single monthly trip to the pharmacy.
- Peace of mind from being able to get medications on time and in one order
- More personal contact with the pharmacist to ask questions and discuss medications.
- Increased understanding of your medication, its purpose, potential side effects and costs.
- Your prescription records will be easily updated to reflect changes to therapy made by Doctors or upon hospital discharge.
doctors or upon hospital discharge.

I understand the program advantages and the following conditions of participation to achieve the maximum benefits from the Simplify My Meds program.

I hereby agree:
- To accept a phone call each month from the pharmacy to discuss my prescription refills.
- To pick up medications on my assigned refill date (or be available for delivery, if applicable)
- If necessary, to pay an extra co-pay one time for each medication in order to make all refills due on the same day.
- To keep an open dialogue with my pharmacist regarding doctor appointments, hospital/urgent care visits, and changes in my health status.
I have read this document, understand it, and have had all questions answered.
Patient Name (please print)*
Date

MonthDayYear
Date
Patient Signature

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Simplify My Meds (Med Pack)