New Patient Application
Please complete and submit the following form and one of our Med Manager staff will verify eligibility and call you back!
Are you signing up for services for yourself or on behalf of another person?
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I am signing up for myself
I am signing up on behalf of someone else
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Phone Number
*
Please enter a valid phone number.
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which of the following prescription insurance options do you have? (select all that apply)
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Medicare Part D
Medicaid
Commercial
I'm not sure
Prescription Insurance Eligibility
*
We can use your MBI (Medicare beneficiary identifier), Medicaid ID, or last 4 digits of your SSN to verify insurance information.
Approximate Prescription Count
Med Manager requires a minimum of 4 monthly prescriptions
Referral
*
First Name
Last Name
Referral's Phone Number
*
Please enter a valid phone number.
Relation to Patient
*
(Spouse, Caregiver, Provider, etc.)
Who should we call back
*
Patient
Referral
Submit
Should be Empty: