Enjoy the convenience of having your prescriptions delivered to your home free of charge! No co-pays OR shipping charges!

Advantages of using EZRx:

Convenient Home Delivery:
Instead of making a trip to your local pharmacy each month, receive up to a three month supply of your prescriptions directly to your home.

Consistent and Reliable Service:
Our representatives will contact you or your physician when refills are due. With EZRx, we will notify you of the status of your order either by email or phone.

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• Required
Patient Name •	Date of Birth (mm/dd/yyyy) •

Physical Address •

Physical Address (Line 2)

City •	State •	Zip Code •
	-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NF NS ON PE QC SK

Email Address •	Daytime Phone •	Alternate Phone

From Prescription Card:

Member ID •	Group Number •

Allergy Info:

No Allergies Codeine Sulfa Aspirin Penicillin Other If other allergies

Health Conditions:

High Blood Pressure Thyroid Diabetes Glaucoma Heart Conditions Other If other condition(s)

Current Medications (including over the counter medicine)

Doctor/Provider Information:

Physician Name

Address

Address (Line 2)

Phone	Fax

 

 

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