RelyPac Intake Form

New Relypac Information
Demographic Information
First and Last Name:
Address:
City:
State:
State:
Zip:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
E-mail
Social Security Number:
Primary Phone Number:
Format: (000) 000-0000.
Cell Phone Number [If Different From Primary]:
Format: (000) 000-0000.
List Allergies to Medications:
Or Upload Medication Allergy List:

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Do you have any specific disease states such as diabetes, high blood pressure etc.
Would you like to pick up RelyPacs at RelyCare Pharmacy monthly or have them delivered?
Please provide any extra information for the Pharmacy if needed
example: My Son John, or my Daughter Jane can pick up my prescriptions, I want one medication in a vial instead of inside packs, I have two different insurance plans... etc
Billing Information
RxBin:
RxPCN:
RxGRP:
ID#:
Is this Insurance through Medicaid?
Copays for medications may be paid via credit/debit card, cash, or check. To avoid delays
we encourage you to keep card information on file at RelyCare. Ask an associate for help.

New Relypac Information
Transfer Information
Please provide your current doctor(s) / specialist(s), and provide your current pharmacy information.
Current Doctor(s) / Specialists(s)
Current Pharmacy:
Current Pharmacy Address:
Current Pharmacy Phone:
Format: (000) 000-0000.
Starting Information
When would you like to start RelyPacs? We require 3 business days between receiving your medications and starting Relypacs. Each weekly pack starts on a Sunday so we prefer to start on a Sunday.
Desired RelyPac Start Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please keep enough medications at home to last you until the RelyPac start date. Bring in the remaining medications to RelyCare Pharmacy to repackage into future RelyPacs.
RelyCare Pharmacy will repackage your prescription medications until they are gone, and will package 4 weeks of your OTC medications then switch to our supply.
RelyCare Pharmacy will automatically fill 4 weeks of RelyPacs every 4 weeks. There will be a monthly charge per 4 weeks. Medicaid patients excluded.
If there is a medication change and you would like RelyCare Pharmacy to repackage the changed medication into or out of RelyPacs, you will be charged per affected card. Medicaid patients excluded.
Relypacs are refilled automatically. Contact RelyCare Pharmacy immediately if you wish to no longer receive RelyPacs. You will be charged a restocking fee if packs were completed.
I understand the instructions above and agree to pay all applicable charges
Please sign here
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

New Relypac Information
Medications
Please provide a medication list or fill out the chart below.

Medication List:

Rows	Medication Name and Strength	Morning	Noon	Evening	Bedtime
1
2
3
4
5
6
7
8
9
10
11
12

Or Upload Medication List:

Please upload a medication list if it will not fit on the table above.
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Should be Empty:

Demographic Information

Billing Information

Transfer Information

Starting Information

Medications