Rx 'n Go Pharmacy Profile Form Your employer provides you ...drug cost savings are significant, and...
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Rx 'n Go Pharmacy Profile Form Patient/Member Instructions Thank you for choosing Rx ‘n Go. Please complete and submit this form if this is your first time using this service. You, and each of your eligible dependents, must submit a separate form to Rx ‘n Go before your first prescription is filled. Submit the profile information one of two easy ways: 1. Online at www.rxngo.com. Complete the online Pharmacy Profile Form and submit. 2. Complete and Fax this form to 888.697.0646. Talk to your physician about all of your current medications in order to avoid potential harmful interaction. If you have questions, contact Rx ‘n Go at 888.697.9646. Patient Information Employer Name: _________________________________________________________________________________________________________ Last Name First Name MI Email Address _____________________________________________________________________________________M________________F______________ Patient Name (if different from above) Patient’s Date of Birth Patient’s Gender ______________________________________________________________________________________________________________________ Patient’s Address (if different from above) City State ZIP Healthcare Provider Information ______________________________________________________________________________________________________________________ Name Telephone Number Verify available generic medications at www.rxngo.com or by telephone, 888.697.9646. Only the healthcare practitioner or designee who authorized the prescription can fax the prescription. To submit a prescription, please fax a 90-day (or longer) prescription along with this form to 888.697.0646 or call in the prescription at 888.697.9646. You can also submit a prescription through E-scribe at Specialty Medical Drugstore. If the patient submits the prescription by mail, the patient must mail the original prescription. Patient Allergies r None r Aspirin r Codeine r Penicillin r Sulfa r Tetracyclin Other (please list)____________________________________________________________________________________________ Patient Conditions r None r Diabetes r Epilepsy r Glaucoma r Heart Condition r Hypertension r Ulcer Other (please list/describe) ____________________________________________________________________________________ _________________________________________________________________________________________________________ I agree to the Privacy Policy of Rx ‘n Go. For a complete copy of the policy, please visit www.rxngo.com or call 888.697.9646. Rx ‘n Go is not a pharmacy. Pharmacy services are provided by Specialty Medical Drugstore, LLC. © 2015 ECB Rx, LLC. All rights reserved. Rx ‘n Go is a trademark of ECB Rx, LLC. * For pharmacy to communicate claims status & information via text messaging. _________________________________________________________________________________________________________ Address City State ZIP Mobile Phone Number*
Transcript of Rx 'n Go Pharmacy Profile Form Your employer provides you ...drug cost savings are significant, and...
More products. Fixed prices.TM
Available to Anyone.
With Rx ‘n Go’s mail service, your prescription drug cost savings are significant, and you save time by eliminating monthly trips to the pharmacy. Keep in mind, that shipping is always free. Once you complete the Patient Profile Form and your prescription is verified,your medication arrives at your door within five to seven business days.
Do you have an existing prescription?Call Customer Service at 888.697.9646 and provide your healthcare provider’s name and phone number, along with the name and strength of your medication. Rx ‘n Go will call your doctor for a new prescription.
Your employer provides you with an affordable and convenient option for meeting your prescription medication needs.
More products. Fixed prices. Available to Anyone.
Rx 'n Go Pharmacy Profile Form
Patient/Member InstructionsThank you for choosing Rx ‘n Go. Please complete and submit this form if this is your first time using this service.You, and each of your eligible dependents, must submit a separate form to Rx ‘n Go before your first prescription is filled.
Submit the profile information one of two easy ways:
1. Online at www.rxngo.com. Complete the online Pharmacy Profile Form and submit.
2. Complete and Fax this form to 888.697.0646.
Talk to your physician about all of your current medications in order to avoid potential harmful interaction. If you have questions, contact Rx ‘n Go at 888.697.9646.
Patient Information
Employer Name:
_________________________________________________________________________________________________________ Last Name First Name MI Email Address
_____________________________________________________________________________________M________________F______________Patient Name (if different from above) Patient’s Date of Birth Patient’s Gender
______________________________________________________________________________________________________________________Patient’s Address (if different from above) City State ZIP
Healthcare Provider Information
______________________________________________________________________________________________________________________Name Telephone Number
Verify available generic medications at www.rxngo.com or by telephone, 888.697.9646. Only the healthcare practitioner or designee who authorized the prescription can fax the prescription. To submit a prescription, please fax a 90-day (or longer) prescription along with this form to 888.697.0646 or call in the prescription at 888.697.9646. You can also submit a prescription through E-scribe at Specialty Medical Drugstore. If the patient submits the prescription by mail, the patient must mail the original prescription.
Patient Allergies
r None r Aspirin r Codeine r Penicillin r Sulfa r Tetracyclin
Other (please list)____________________________________________________________________________________________
Patient Conditions
r None r Diabetes r Epilepsy r Glaucoma r Heart Condition r Hypertension r Ulcer
Other (please list/describe) ____________________________________________________________________________________
_________________________________________________________________________________________________________
I agree to the Privacy Policy of Rx ‘n Go. For a complete copy of the policy, please visit www.rxngo.com or call 888.697.9646. Rx ‘n Go is not a pharmacy. Pharmacy services are provided by Specialty Medical Drugstore, LLC.
© 2015 ECB Rx, LLC. All rights reserved. Rx ‘n Go is a trademark of ECB Rx, LLC.
Your company offers you a choice. You can receive up to a 90-day supply of generic maintenance drugs by mail, at no cost to you through Rx ‘n Go. With the Rx ‘n Go prescription savings program you receive:
• Up to a 90-day* supply of your prescribedgeneric drugs from a list of nearly 1,200covered medications, conveniently delivered to your home at absolutely no cost to you.
• A diabetic monitor and test strips from ProdigyR, if applicable.
• Automatic refills are available for orders from physicians for more than 90 days. Simplycontact Customer Service and ask to enrollin Auto Refill.* State and federal laws limit controlled substances supply.
No Cost to You – FREE, Generic, Medication Shipped to Your Home!
* For pharmacy to communicate claims status& information via text messaging.
_________________________________________________________________________________________________________ Address City State ZIP Mobile Phone Number*
