MTM Online Application

Insurance Policy Holder Information

First Name (required)

Last Name (required)

Address (required)

Address (cont.)

City (required)

State (required)

ZIP (required)

Insurance Member ID

Insurance Group Code

Rx BIN #

PCN #

Daytime Phone (required)

Evening Phone

Email (required)

Please send me email notices about the status of the enclosed prescription(s) and online ordering.

MedicoRx® will keep this address on file for all orders from this membership until another shipping address is provided by anyone in this membership.

Referral Group Code

How did you hear about us?

Prescription Recipient Information

Fill out a separate section for EACH person requesting filled prescriptions. If she/he has prescriptions from more than one doctor, complete a new section for each doctor. NOTE: Only 4 sections are included on this online form. If more are required, this information can be relayed via phone or email once the application is submitted.

SECTION ONE

First Name (required)

Last Name (required)

Birthdate (MM/DD/YYYY) (required)

Sex(M or F) (required)

Patient's relationship to Rx insurance holder. (required)

SelfSpouseDependentDomestic Partner

Doctor's Last Name (required)

Doctor's First Initial (required)

Doctor's Phone # (required)

SECTION TWO (if needed)

First Name

Last Name

Birthdate (MM/DD/YYYY)

Sex(M or F)

Patient's relationship to Rx insurance holder.

SelfSpouseDependentDomestic Partner

Doctor's Last Name

Doctor's First Initial

Doctor's Phone #

SECTION THREE (if needed)

First Name

Last Name

Birthdate (MM/DD/YYYY)

Sex(M or F)

Patient's relationship to Rx insurance holder.

SelfSpouseDependentDomestic Partner

Doctor's Last Name

Doctor's First Initial

Doctor's Phone #

SECTION FOUR (if needed)

First Name

Last Name

Birthdate (MM/DD/YYYY)

Sex(M or F)

Patient's relationship to Rx insurance holder.

SelfSpouseDependentDomestic Partner

Doctor's Last Name

Doctor's First Initial

Doctor's Phone #

Prescription Change

Provide detail on prescriptions currently filled elsewhere that you would like filled through MedicoRx®. NOTE: For each medication, provide the following: Medication Name, Patient's Medication Rx Number, Remaining Medication Days, Pharmacy Name, Pharmacy Phone Number.

Enter all info HERE:

Prescription Transfer Information

Please choose ONE of the following.

My physician or healthcare provider will fax my prescriptions.My physician or healthcare provider will e-prescribe my prescriptions to MedicoRx®.I will transfer the prescriptions from my current pharmacy.

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