• This form has been simplified

    Only fields in red are required.

  • We're sorry, we no longer can activate pre-made pharmacy cards. We will issue a digital card right to your Email. Please do not show your physical card to the pharmacy as the information on it is no longer correct.

  • PROVE Partners has been banned due to non-payment. All existing pharmacy cards have been closed and no new cards can be activated at this time.

  • Patient Information

    Only fields in red are required
  •  / /
  •  / /

  • Attorney Information

    Only fields in red are required

  • Case Information

    If you do not have this information yet or it is not applicable, you can type "Unknown" or "N/A" in any field

  • Patient lookup

    The more info you add, the less likely there will be errors
  •  / /
  •  / /

  • Card Controls

  •  / /

  • *New Feature*

    Prescription Coverage Options:

    • Cover pain/inflammation prescriptions - Pain, inflammation, triptans, SSRi's, muscle relaxants, PPI's, antibiotics, and other likely injury or related medicines will be covered by default. All other medications will be rejected unless added to coverage.
    • Cover any prescription - No restrictions, all drugs are covered by default. 

  • Pharmacy Information

    Have the prescription filled ahead of time

  • 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.

  • 0/249
  • Browse Files
    Cancelof
  • Clear
  • Should be Empty: