Order Request NEW 2.27.25

Get Started!

Begin your Medicaid order today! Call us anytime at +1(866) 270-3322. Make sure to have your insurance card ready!
New Patient Information

All information is protected by HIPPA. 100% Secure. Patient and insurance information must match.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Mobile Phone*
Email*
example@example.com
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about us?*

FaceBookGoogleAssisted Living FacilityReferralOther
"Wellness begins with care—let’s take this journey together."

New Patient Insurance & Doctor Information

We'll use this to contact your doctor and obtain your most recent prescription. We'll handle all of the paperwork so you don't have to!
Medicaid Insurance State*
KY Insurance Provider*
NE Insurance Provider*
IA Insurance Provider*
Please list your insurance provider*
Medicaid Member ID Number*
Your Medicaid member ID number is usually on the front of your Medicaid card, labeled as "Member ID". Please submit images below if you need help or are unsure.
Insurance Card Front Photo
Have you seen your doctor in the last 12 months?*

YesNo
Doctors Name*

First NameLast Name
Doctors Phone Number*
Doctors Fax Number (optional)
"Small steps lead to big progress. Keep moving forward on your health journey."

Get Started!