Please complete the following information. You will receive a follow-up notification from a VeracityRx Associate within 24-48 business hours to discuss your case.

Patient Information Profile

* = Required fields

Patient Name

Patient First Name  *

Patient Last Name  *

Employer of Insured  *   


Primary Insured First Name & Last Name (if different from above)

Insured First Name

Insured Last Name

Please provide details of your primary drug insurance below. Or, if you prefer, you can upload a copy of your insurance card located at the bottom of this form (and click the box indicating you have done so).

If you have not received your insurance card, or aren't sure what to enter, please put N/A or UNKNOWN in each field.

Member ID Number  *

Bin Number  *

RX Group Number  *

  I have uploaded a copy of my Insurance Card  *   

If you have a current manufacturer copay assistance card, please provide a copy. You can upload a copy at the bottom of this form.


Does the Patient have any other drug coverage (i.e., Medicaid, secondary coverage)?  *   


Are you in a high deductible healthcare plan with a Health Savings Account (HSA)?  *   
 Yes
 No

Patient Date of Birth  *   


Gender  *   

Cell Phone Number  *		Send notifications by text message   YES
Home Phone Number  *		Notify me by phone call   YES
Patient Personal Email Address  *		Send notifications by email   YES
(Please be aware that work email addresses could be blocked)

Patient Mailing Address  *   


City  *   

State  *    select AK - ALASKA AL - ALABAMA AR - ARKANSAS AZ - ARIZONA CA - CALIFORNIA CO - COLORADO CT - CONNECTICUT DE - DELAWARE FL - FLORIDA GA - GEORGIA HI - HAWAII IA - IOWA ID - IDAHO IL - ILLINOIS IN - INDIANA KS - KANSAS KY - KENTUCKY LA - LOUISIANA MA - MASSACHUSETTS MD - MARYLAND ME - MAINE MI - MICHIGAN MN - MINNESOTA MO - MISSOURI MS - MISSISSIPPI MT - MONTANA NC - NORTH CAROLINA ND - NORTH DAKOTA NE - NEBRASKA NH - NEW HAMPSHIRE NJ - NEW JERSEY NM - NEW MEXICO NV - NEVADA NY - NEW YORK OH - OHIO OK - OKLAHOMA OR - OREGON PA - PENNSYLVANIA RI - RHODE ISLAND SC - SOUTH CAROLINA SD - SOUTH DAKOTA TN - TENNESSEE TX - TEXAS UT - UTAH VA - VIRGINIA VT - VERMONT WA - WASHINGTON WI - WISCONSIN WV - WEST VIRGINIA WY - WYOMING

Zip Code  *

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Below are two separate drug lists. Please review both lists and select the drug(s) you are currently prescribed. If your drug(s) are not present on either list, please provide the name of each prescription medication not listed.

Please select the Personal Importation Drug(s) you are prescribed.

Please select the Specialty Drug(s) you are prescribed.

Please include the strength of the drug(s) you are prescribed.  *   


This drug(s) is used to treat what condition?  *   


List any Allergic Reaction you may have had and the name of the drug which caused the reaction.  *   


Doctor (prescriber) name for the drug(s) above  *   


Doctor (prescriber) phone number for the drug(s) listed above  *   


Doctor (prescriber) fax number for the drug(s) listed above  *   


Please list any other drugs you are currently taking  *   

Please check box to grant permission to contact the prescriber on your behalf regarding your medication(s).

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Is Patient a Smoker or Non-Smoker?  *   

 Non-Smoker
 Smoker

Are you allergic to Latex?  *   

 Yes
 No

Are you a Veteran?  *   

 Yes
 No

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