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

Prescription Mart, PO Box 12607, Beaumont, TX  77726

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

           

PATIENT PROFILE FORM

Male           Female  

Employer  Group# 
Cardholder Name 
Phone Number 

Date of Birth

Address 
City  State Zip 

Family Doctor's Name

Dr.'s Phone Number
Does the employee have drug allergies/sensitivities?  Yes  No If yes, please describe:
Chronic disease?  Yes   No If yes, please describe

Current medications? Yes   No

If yes, please list all medications,
including over the counter, that
are not filled by Prescription Mart

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.
Cardholder Id # 
Signature  Date 
 

DEPENDENTS

Please list all eligible dependents.

If an eligible dependent in your family has any allergies, chronic diseases, is sensitive to any drugs, or is currently taking medications (including over the counter) not filled by Prescription Mart, please describe.

If you have no eligible dependents, check this box. 

Dependent 1
Patient's Name Relationship
DOB Sex
Dr.'s Name
Drug Allergies/Sensitivities  Yes  No If yes, please describe
Chronic diseases  Yes  No If yes, please describe
Current Medications  Yes  No If yes, please describe
Dependent 2
Patient's Name Relationship
DOB Sex
Dr.'s Name
Drug Allergies/Sensitivities  Yes  No If yes, please describe
Chronic diseases  Yes  No If yes, please describe
Current Medications  Yes  No If yes, please describe
Dependent 3
Patient's Name Relationship
DOB Sex
Dr.'s Name
Drug Allergies/Sensitivities  Yes  No If yes, please describe
Chronic diseases  Yes  No If yes, please describe
Current Medications  Yes  No If yes, please describe
Dependent 4
Patient's Name Relationship
DOB Sex
Dr.'s Name
Drug Allergies/Sensitivities  Yes  No If yes, please describe
Chronic diseases  Yes  No If yes, please describe
Current Medications  Yes  No If yes, please describe
Dependent 5
Patient's Name Relationship
DOB Sex
Dr.'s Name
Drug Allergies/Sensitivities  Yes  No If yes, please describe
Chronic diseases  Yes  No If yes, please describe
Current Medications  Yes  No If yes, please describe
Dependent 6
Patient's Name Relationship
DOB Sex
Dr.'s Name
Drug Allergies/Sensitivities  Yes  No If yes, please describe
Chronic diseases  Yes  No If yes, please describe
Current Medications  Yes  No If yes, please describe