VeracityRx Enrollment Form

    Welcome!



  Email: help@veracity-rx.com

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

* = 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



Patient Mailing Address  *   

(Please be aware that work email addresses could be blocked)

City  *   


State  *   
Zip Code  *   





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.

    Anoro Ellipta     Apidra     Apidra Solostar     Arnuity Ellipta     Atripla
    Basaglar Kwikpen     Biktarvy     Breo Ellipta     Brilinta     Combivent Respimat
    Descovy     Dulera     Eliquis     Entresto     Farxiga
    Fiasp     Flovent HFA     Ibrance     Incruse     Invokamet
    Invokana     Isentress     Janumet     Janumet XR     Januvia
    Jardiance     Juluca     Multaq     Myrbetriq     Omnaris
    Ozempic     Prezcobix     Qvar     Rexulti     Rybelsus
    Silenor     Spiriva Respimat     Sprycel     Tivicay     Toujeo Solostar
    Tradjenta     Trelegy Ellipta     Trintellix     Trulance     Trulicity
    Tudorza     Victoza     Xarelto


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


    Actemra     Adempas     Afinitor     Aubagio     Avonex
    Benlysta     Cimzia     Cosentyx     Dupixent     Enbrel
    Firazyr     Gilenya     Haegarda     Humira     Humira CF
    Kuvan     Norditropin AQ     Opsumit     Orencia     Otezla
    Pulmozyme     Rebif     Revlimid     Rinvoq     Simponi
    Skyrizi     Stelara     Strensiq     Sutent     Tagrisso
    Taltz     Tobi Podhaler     Tremfya     Tyvaso     Vemlidy
    Vumerity     Xeljanz     Xeljanz XR     Xolair     Zelboraf

OTHER (my drug is not listed)

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).  



Is Patient a Smoker or Non-Smoker?  *   

 Non-Smoker
 Smoker


Are you allergic to Latex?  *   

 Yes
 No


Are you a Veteran?  *   

 Yes
 No




If you are enrolling and your medication(s) is/are available to source through the personal importation program, please confirm that you understand the medication(s) will be fulfilled from a Canadian pharmacy, and you authorize this shipment from Canada.

Please check the box to confirm.   



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Questions? Need help? Email: help@veracity-rx.com

      Your information is saved directly to VeracityRx in a secured format.



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