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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:*    
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*
() - -   
Secondary Phone Number
() - -   
Email address:
@.
May we leave a message regarding your medications on these phone lines?     
May we leave a message regarding your medications with other members of your household?     

Drug Allergies (check all that apply) Medical Conditions (check all that apply)



















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?     

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
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