Activate Pharmacy Card

Patient Information
Patient First *
First Name
Patient Last *
Last Name
Date of birth *

Month Day Year
ex. 01/05/1976
Sex

Male Female Unspecified
Patient Phone
A copy of the card will be texted here
Patient Email
A copy of the card will be sent here
Patient Address 1
ex. 123 Main St.
Patient Address 2
ex. Apartment #105
City
State
Zip

Attorney Information
Has the Law Firm contact info changed since last request?

Yes No
Law Firm *
Attorney name *
Attorney Email *
Lien and User Agreement will be sent here
Attorney Phone *
Attorney Fax
Attorney Address 1 *
ex. 123 Main St.
Attorney Address 2
ex. Suite #105
City *
State *
Zip *
Paralegal Name
If left blank, the Attorney will be the primary contact.
Paralegal Email

Case Information
Injury date *

Month Day Year
01/05/2018
Case type
Liability
Property damage
Were damages resolved favorably?

Yes No
Total medical bills
(not including prescriptions)
Policy limits

Patient lookup

The more info you add, the less likely there will be errors
Patient name *

First Name Last Name
Patient ID
Pharmacy Card #
Birth date

Month Day Year
ex. 01/25/1976
Injury date

Month Day Year
ex.01/05/2018

Pharmacy Information

Have the prescription filled ahead of time
Do you want a copy of the pharmacy card sent to a specific pharmacy? *

Yes No
Pharmacy name *
Pharmacy Email
Pharmacy phone *

Area Code Phone Number
Pharmacy fax *

Area Code Phone Number

Submit Form
***IMPORTANT UPDATE***

The Pharmacy Card Program now only covers prescription generic pain and inflammation medications.

If you or your client is trying to fill: Over the counter, Name Brand, Non-pain, or Non-inflammation medications, please enter the Drug Name and Strength (e.g., Valium 5mg) to the 'Comments' section below.

You can also upload a copy of the prescription below or call ahead (844) 796-3322 include non-approved medications to the Pharmacy Card.
Comments

For special instructions, notes, or comments. 0/250
Upload prescription

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