Home About You (Enroll) Browse the Pharmacy Medical Products Product Index Prescription Medications SOS Lifesaving ID Bracelet Impotence Treatment Blood Glucose Meters Meters Home TrueTrack Smart System (pdf) TrueTrack Promotion (pdf) Strips Lancets Insulin Pumps & Supplies Health Information Diabetes Index General Information What You Should Know Oral Meds & Type II Diabetes The New Food Label Monitoring Your Blood Sugar Your Eyes Nerve Disease Kidney Disease Your Heart Diet and Exercise Living with Diabetes Price Lookup Online Refills About Us Contact Us Your Privacy			Enrollment Form Please call our customer service department at 1-800-682-8283 if you have an immediate need for medications or have any questions regarding Advantage Health Services products or enrollment. We look forward to assisting you. Patient's Name:                             Gender:*  M  F First* M.I. Last* Date Of Birth* // MM  /   DD  /  YYYY* Social Security # - - *This is not a required field but may be needed to verify insurance coverage Patient's Mailing Address:       Street* Apt #       City* State* Zip Code* Shipping Address (if different):       Street Apt #       City State Zip Code Primary Phone Number* () - -   DayEveAnytime Secondary Phone Number () - -   DayEveAnytime Email address: @. May we leave a message regarding your medications on these phone lines?  Yes   No May we leave a message regarding your medications with other members of your household?  Yes   No Drug Allergies (check all that apply) Medical Conditions (check all that apply) Aspirin Codeine No Known Allergies Penicillin Sulfa Tetracycline Other Asthma COPD Diabetes Epilepsy Glaucoma Heart Condition High Blood Pressure Nursing Mother Pregnant Prostate Condition Respiratory Condition Thyroid Condition Ulcers Other Insurance Information Company Name: Street Address: City: State, ZipCode:    Phone Number: () - - Contact Person: Name of Insured: Employer: ID Number: Group Number: Person Code: *Insurance Information is required if your prescription medications and/or supplies are covered by your insurance and you want AdvantageRx to bill your insurance company. Primary Physician Information Name:* Phone:* () - - Are all the medications you take prescribed by this physician?   Yes   No Secondary Physician's Information Name: Phone: () - - Please List Your Current Medications and/or Supplies: By entering my name below, I authorize Advantage Health Services to: 1. Promptly verify my prescription coverage under the above identified insurance plan. 2. Call me to confirm my prescription coverage and delivery date for my medications. 3. Obtain prescription information from the physician identified above. I understand that I will be responsible for the cost of my medication if Advantage Health Services does not receive payment in full directly from my insurance company or Payor. I agree to provide Advantage Health Services with a copy of my insurance card. Authorization:* Required fields are indicated with a red * and bolded.

For further information please contact us at 1-800-682-8283 or complete the convenient enrollment form and we will contact you. Copyright © 2004-2008 Advantage Health Services 300 TechneCenter Dr, Suite B • Milford OH 45150 Phone: 1-800-682-8283 • Fax: 513-248-3079 • Email: advantagerx@pbmplus.com Last modified: March 13, 2008 Notice of Privacy Practices