Name*

First NameLast Name

Phone Number (Home)*

Phone Number (Mobile)

Please enter a valid phone number.

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Last 4 Digit of SSN: *

Date of Birth *

Date

Associated/Facility*

Allergies*

Primary Doctor Name:*

First NameLast Name

Doctor Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Doctor Phone #*

Please enter a valid phone number.

Insurance Company Name*

Insurance Phone Number

Please enter a valid phone number.

Cardholder ID #

Bin #

Group #

PCN #

Secondary Insurance Company Name

Insurance Phone Number

Please enter a valid phone number.

Cardholder ID #

Bin #

Group #

PCN #

Does anyone help manage your medications, such as a family member or home-care agency? If Yes, please complete thissection:

Caregiver Name

Caregiver Phone #

Please enter a valid phone number.

Is this a home care agency

Yes , please answer the question below.No

Name of Home Care Agency

Type of Packaging for your Medication*

Terms and Conditions

By checking each box, I acknowledge and understand and agree:*

To implement AidRX program and automatically refill my prescription every month.To accept a monthly outreach call from MMP PAR to discuss any info regarding prescription.To play an active role in prescription & medical management and ensure pharmacy is notified of doctor visits, hospital orurgent care visits, medication changes or additional or any changes in health status.To receive a 30 day supply of medication.That your AidRX box is not child resistant and should be stored in a safe place out of reach of children.To grant authorization to AidRX pharmaceuticals to contact my current pharmacy provider and transfer my prescriptions.To grant authorization to AidRX pharmaceuticals to contact my doctor (s) to obtain authorization for new prescriptions andexchange relevant health information with my doctor(s).To be available for scheduled deliveries (in the event I, or designated individual, am not available for a non-complaint with scheduled deliveries a $20.00 re-delivery fee will be charged.The medication box will be hand delivered to your resident.

Name*

First NameLast Name

Relationship*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signature*

Date*

Date

Enrollment Form

Terms and Conditions

Emergency Contact