CANARX Enrollment Form

Complete this form to request a CANARX representative reach out to complete your enrollment in the program and place your first order. Please note that completing this form does not automatically enroll you in the program but it is the first step. By submitting this form, you authorize a CANARX representative to contact you directly to help complete your enrollment to this great program. Welcome to CANARX!

Prior to completing this form, please confirm you are taking one of the medications offered on your plan formulary HERE.

* Indicates a required field
WebID
Name of Employer*
Patient Information

Complete a form for each member enrolling in the program
Member ID
If unsure, please leave blank
Date of Birth*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Phone Type*
2nd Phone Number
Please enter a valid phone number.
2nd Phone Type
Type*

SubscriberDependent
SEX*

MaleFemale
CANARX Prescription Medications

List all medications you wish to fill through the CANARX program.
Other Medications/Vitamins

List all other prescription, non-prescription and over-the-counter medications as well as herbal, nutritional and vitamin supplements.
Would you like CANARX to reach out to your prescriber to obtain a prescription on your behalf?*

YesNo
Prescriber's Information
First NameLast Name
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Fax
Please enter a valid number.
Photo ID
An image of your valid government-issued photo ID is required for registration.

Accepted image types: pdf, jpg, jpeg, png, tif, tiff
Cancelof
Medical History
Medical Procedures / Operations*

YesNo
Specify Operations*
Hospitalizations (During the past 5 years)*

YesNo
Specify Hospitalizations*
Medical Conditions*

YesNo
Note: Please refrain from using generic terms such as “heart disease” as this could indicate any number of conditions such as valvular heart disease, heart failure, a bradyarrhythmia, a tachyarrhythmia, a ventricular conduction delay, etc.
Specify Medical Conditions*
Drug Allergies*

YesNo
Specify Drug Allergies*
Authorization
Patient Type*

Dependent child under age 18Subscriber, spouse, or dependent child age 18 and over
If the patient is a dependent child under age 18

I certify this to be a true and accurate statement of my Dependent’s medical history. I confirm that he/she has been, and will be, regularly monitored by a U.S. Physician and has had a physical examination within the past 12 months. I verify that he/she has taken the above listed medications for a period of more than 30 days. I certify that I have read, understand and agree to the Terms of Agreement, and that the information provided above is accurate and true.
Parent's/Guardian's Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
If the patient is the subscriber, spouse, or a dependent child age 18 and over

I certify that I have read, understand, and agree to the Terms of Agreement as accepted by me on this or a prior or subsequent screen and that the information provided by me is accurate and true.
Patient's Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

Patient Information

CANARX Prescription Medications

Other Medications/Vitamins

Prescriber's Information

Photo ID

Medical History

Authorization

If the patient is a dependent child under age 18

If the patient is the subscriber, spouse, or a dependent child age 18 and over