Enrollment Form
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
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* = Required fields
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Patient Name
Employer of Insured
*
Primary Insured First Name & Last Name (if different from above)
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.
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
*
Patient Mailing Address
*
(Please be aware that work email addresses could be blocked)
City
*
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.
If your drug(s) is not listed, please provide the drug(s) name:
If you chose a "Specialty" drug or selected "Other", please select your
household size and income range below:
Number of people living in Patient Household
*
Household Annual Income Range (USD)
*
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
*
Is Patient a Smoker or Non-Smoker?
*
Non-Smoker
Smoker
Are you allergic to Latex?
*
Yes
No
Are you a Veteran?
*
Yes
No
Attached Files
Select files to upload
.pdf,.png,.jpg,.jpeg,.tif,.tiff,.gif
Common error text is displayed here
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Questions? Need help? Email:
help@veracity-rx.com
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Your information is saved directly to VeracityRx in a secured format.
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