Pharmacy Card Portal
Request type
*
Activate NEW card
Modify EXISTING card
Request card status
What would you like to modify?
*
Reactivate a card
Deactivate a card
Change card parameters
Your name
*
(the person filling out this form)
Your Email
*
example@example.com
Who are you?
*
Attorney
Doctor
Patient
Medical Funding Company
Your phone number
*
(the person filling out this form)
Are you activating a pre-made pharmacy card?
*
Yes
No
Funder ID
*
Include pricing group code (i.e., BV20)
Member ID
*
Type the ID of your pre-made card
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Patient Information
Patient First
*
First Name
Patient Last
*
Last Name
Date of birth
*
/
Month
/
Day
Year
ex. 01/05/1976
Sex
*
Male
Female
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
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Attorney Information
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
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Case Information
Injury date
*
/
Month
/
Day
Year
01/05/2018
Case type
Auto accident
Premises
Dog bite
Commercial
Product
Malpractice
Workers Compensation
Other
Liability
Admitted
Confirmed
Clear
Denied
Other
Property damage
Total medical bills
(not including prescriptions)
Policy limits
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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
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Card Controls
Maximum Card Limit
*
$999,999
$500
$1000
$1,500
$2,000
$3,000
$4,000
$5,000
$7,500
$9,000
$12,000
$20,000
$50,000
$999,999
Expiration Date
*
/
Month
/
Day
Year
Prescription Coverage
*
Cover any prescription
Cover specified prescriptions
Approved Medications
*
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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
No dashes or parenthesis please, just numbers.
Pharmacy fax
i.e., 8005551212
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Next
Submit Form
Comments
For special instructions, notes, or comments.
Upload prescription
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