Language
English (US)
Español
NASH Patient Information Form
Patient Information
Name
Patient First Name
Patient Last Name
Date of Birth
-
Month
-
Day
Year
Date
Country of Residence
Sex
Marital Status
Guardian/Legal Representative
Guardian/Legal Representative First Name
Guardian/Legal Representative Last Name
Upload a photo of the patient's State-issued Personal Identification (examples: passport, driver's license, or government identification card); If the patient is a minor, please upload a photo of the ID belonging to their Parent/Guardian/Legal Representative.
*
Browse Files
Drag and drop files here
Choose a file
A photo of your official ID must be on file before we can ship medications (450 KB minimum size)
Cancel
of
Social Security Number (note: if the patient is a minor, please provide the social security number of Parent/Guardian/Legal Representative)
*
Passport or Driver's License# (note: if the patient is a minor, please provide the Passport or Driver’s License number of their Guardian/Legal Representative.)
*
Email
Other Identification (note: if the patient is a minor, please provide the identification of the Parent/Guardian/Legal Representative)
*
Passport Number
Driver's License
Other government issued personal identification
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Which contact number do you prefer? (Please provide the best number to reach you. If the patient is a minor, please provide the best number for their Guardian/Legal Representative.)
Home
Work
Mobile
Preferred Language
Name of Employer
Did a coworker refer you to NASH? If so, they may be eligible for rewards as part of our Share the Care Patient Referral Program! (Click here for more information)
First Name
Last Name
Back
Next
Prescription Information
Specialty Drug Name(s)
Specialty Drug(s) to be filled by NASH
Please provide the number of days of medication you still have available?
Number of days
Photo of Prescription Label(s)
Browse Files
Drag and drop files here
Choose a file
Upload up to 3 photos of the prescription medication label(s) to be filled by NASH
Cancel
of
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Personal/Authorized/HIPAA Representative
Personal/Authorized/HIPAA Representative (The person, usually a family member, friend, or legal guardian, designated under state law to make health care decisions and manage your information on your behalf.)
Representative First Name
Representative Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred contact number?
Home
Work
Mobile
Relationship to Patient
Back
Next
Provider Information
Provider Name
Provider First Name
Provider Last Name
Clinic/Hospital
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
Please enter a valid fax number.
Format: (000) 000-0000.
Prescriber Treating Current Condition (if applicable)
Name
Prescriber First Name
Prescriber Last Name
Clinic/Hospital
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
Please enter a valid fax number.
Format: (000) 000-0000.
Health Insurance Information (if applicable)
Name of Insurance
Name of Policy Holder (if other than patient)
Policy/Member ID Number
Phone Number of Insurance
Please enter a valid phone number.
Format: (000) 000-0000.
Effective Date of Policy
-
Month
-
Day
Year
Date
Termination Date of Policy
-
Month
-
Day
Year
Date
Back
Next
Prescription Insurance Information (if applicable)
Name of Insurance
Name of Policy Holder (if other than patient)
Policy/Member ID Number
Phone Number of Insurance
Please enter a valid phone number.
Format: (000) 000-0000.
Effective Date of Policy
-
Month
-
Day
Year
Date
Termination Date of Policy
-
Month
-
Day
Year
Date
Consent and Signature
By checking the box(es) below, you confirm your consent to receive messages from NASH.
By checking this box, you confirm your consent to receive voicemail or secure email messages from NASH for important reminders regarding your prescription, including delivery/refill updates.
By checking this box, you confirm your consent to receive transactional SMS messages from NASH regarding important reminders regarding your prescription, including delivery/refill updates. Message and data rates may apply. Text HELP for more information or STOP to opt out. Message frequency may vary. View our privacy policy here: https://nashcares.com/privacy-policy/
By checking this box, you confirm your consent to receive marketing SMS messages from NASH. Message and data rates may apply. Text HELP for more information or STOP to opt out. Message frequency may vary. View our privacy policy here: https://nashcares.com/privacy-policy/
Patient or Guardian/Legal Representative
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Signature of Patient or Guardian/Legal Representative
Continue
Continue
Should be Empty: