Step 1:  Print form, fill out completely & mail to:

Prescription Mart, PO Box 12607, Beaumont, TX  77726

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT PROFILE FORM

Male           Female  

Employer  Group# 
Employee Name 
Phone Number 

Date of Birth

Address 
City  State Zip 

Family Doctor's Name

Dr.'s Phone Number

Does the employee have allergies?

Yes  No

If yes, please describe: 

Chronic disease?

Yes   No

If yes, please describe: 

Sensitivity to drugs?

Yes   No

If yes, please describe: 

CERTIFICATION STATEMENT

IMPORTANT:I certify that the patient information entered on this form is correct and that the patient named is eligible for benefits under the Prescription Drug Program. I hereby assign to the provider pharmacy any payment due pursuant to this transaction and authorize payment directly to the provider pharmacy. I also authorize release of all information pertaining to the claim to the plan administrator, underwriter, sponsor, policyholder and employer. I have read the CERTIFICATION STATEMENT and hereby certify to and accept the terms thereof.
Employee's Cardholder Id # 
Employee's Signature  Date 

List all eligible dependents below:

If an eligible dependent in your family has any allergies, chronic diseases, or is sensitive to any drugs, list below.

If you have no eligible dependents, check this box. 

Patient's Name Relationship DOB  

Sex   Allergy/Sensitivity Dr.'s Name

Patient's Name Relationship DOB  

Sex   Allergy/Sensitivity Dr.'s Name

Patient's Name Relationship DOB  

Sex   Allergy/Sensitivity Dr.'s Name

Patient's Name Relationship DOB  

Sex   Allergy/Sensitivity Dr.'s Name

 

 

Prescription Request Form

Number of Rx's enclosed  Amount of co-payment enclosed $

The prescriptions enclosed are for: (Fill in name and date of birth for dependents.)

Employee          

 Son

Date of Birth

Student

Spouse               

Daughter

Date of Birth

Student

Check enclosed   Please charge my credit card 

Visa  or  MasterCard  Discover        Bank card No.

Exp. Date