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Enrollment Form

Serve You Rx Home Delivery Pharmacy Enrollment Form

If you need additional forms, click here.

PRESCRIPTION BENEFIT CARDHOLDER INFORMATION

Look for the following information on your prescription ID card.

Prescription Benefit Plan Name:

Member ID #: Rx Group #: Rx BIN #: PCN:

Last Name: First Name: MI:

Date of Birth:

Gender: Male Female Other

Email Address:

Permanent Address: City: State: ZIP:

Use a different address for deliveries

Delivery Address: City: State: ZIP:

Primary Phone #: Mobile

Alternate Phone #: Mobile

MEDICATION ALLERGIES

No known allergies

Amoxil/Ampicillin

Aspirin

Cephalosporins

Codeine

Erythromycin

Iodine

Penicillin

Quinolones

Sulfa drugs

Tetracyclines

Others:

HEALTH CONDITIONS

None

Acid Reflux

Arthritis

Asthma

Depression

Diabetes

Epilepsy

Glaucoma

Heart problem

High blood pressure

High cholesterol

Migraine

Osteoporosis

Prostate issues

Thyroid – low/high

Others:

ADDITIONAL PROCESSING INFORMATION

Notes To Pharmacy:

Generic Substitution: FDA-approved generic equivalents will be dispensed for brand-name drugs whenever possible, unless you or your physician indicate otherwise. Brand-name medications may be subject to a higher cost.

PAYMENT & SHIPPING

A pharmacy representative will contact you prior to shipment of your first order to set up a payment method.

Standard processing time for orders is 2–3 business days from the date the completed order is received at the pharmacy. Please allow additional time for delivery when placing your order. Serve You Rx will contact you if there will be a delay in processing your order. Once shipped, medications may not be returned for a refund or adjustment.

Thank You!

Thank you for your submission. Your enrollment has been received and your account will be created within 24 hours. Please have your provider send prescriptions electronically to Serve You DirectRx or fax
to 866-494-0364.

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Oops. We are experiencing technical difficulties. Please try again later or contact Serve You Rx customer service to enroll at 800-759-3203.

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About Serve You Rx

We have been an independent, privately held, full-service PBM since 1987. Built on a reputation for service excellence, we have expanded our capabilities from the ground up with our hardworking team and proven process for managing drug spend with innovative and cost-effective benefit solutions.

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About Serve You Rx

We have been an independent, privately held, full-service PBM since 1987. Built on a reputation for service excellence, we have expanded our capabilities from the ground up with our hardworking team and proven process for managing drug spend with innovative and cost-effective benefit solutions.

Company

Home

About Us

careers

Contact Us

Partners

Partners Home

What We Do

Who We Are

Pharmacies

RFP Form

Providers

Providers Home

Drug Lists

Provider's Forms

Members

Members Home

Member Portal

EZRefillRX

FAQs

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