Enrollment Form

Enrollment Form
Name*

First NameLast Name
Phone Number (Home)*
Format: (000) 000-0000.
Phone Number (Mobile)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 Digit of SSN: *
Date of Birth *

MonthDayYear
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.Format: (000) 000-0000.
Insurance Company Name*
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cardholder ID #
Bin #
Group #
PCN #
Secondary Insurance Company Name
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Yes , please answer the question below.No
Name of Home Care Agency
Type of Packaging for your Medication*
Terms and Conditions
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.
Emergency Contact
Emergency Name*

First NameLast Name
Emergency Relationship*
Emergency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Enrollment Form

Terms and Conditions

Emergency Contact