Toll-free: 1.888.239.7690
TTY: Please dial 711 for phone relay assistance
Customer Service Hours:
M-F 8am - 8pm EST, Sat 10am - 2pm EST
Member Enrollment Form
PERSONAL INFORMATION
Name:
Date of Birth (mm/dd/yy): Gender: Male Female
Add
ress
:
City: State:
Zip Code:
Home Ph
one: Cell Ph
one:
Email Addres
s:*
Em
ergency Contac
t:
Phone:
Relationship to Member:
Authorized to disclose information
Allergies: None Aspirin Codeine Iodine Penicillin Sulfa Other:
Health Condition(s): Thyroid Diabetes Arthritis Heart Conditions High Blood Pressure Depression
Asthma High Cholesterol
Oth
er:
*By providing your email address, you consent to receive email notifications regarding your prescription benefits, as well as other information on behalf of Homescripts and
Envolve Pharmacy Solutions. You may opt out of this email service at any time by contacting us or following the opt-out instructions included in each email you receive.
HEALTHCARE PRACTITIONER INFORMATION
Name (Printed): Phone: Fax:
PRESCRIPTION INSURANCE INFORMATION
Policyholder (if different than above):
Relationship to Member:
Cardholder ID #: Rx Group:
Rx BIN #: PCN/Plan Code:
Insur
ance Name: Ins
urance Phone:
PAYMENT INFORMATION
Credit Card Type: Visa Mastercard Discover
Amex
Use this card for fut
ure orders? Yes No
Credit Card #: Expirati
on Date:
Is this an FSA card? Yes No
(Turn over to complete)
Cardholder Name: Cardholder Signature:
2019
click to sign
signature
click to edit
Member Enrollment Form
MEDICATION HISTORY
Please list all prescription and over-the-counter medications you are currently taking.
Medication Name Strength
PRESCRIPTION INFORMATION
Please allow 7-10 business days to
receive your medication orders.
Notify your doctor that you are now
using Homescripts Pharmacy and to
ePrescribe your prescriptions.
Homescripts Pharmacy
500 Kirts Blvd., Suite 300
Troy, MI 48084
Phone: 1.888.239.7690 TTY: Please dial 711
Fax: 877.396.5970
customerservice@homescripts.com
US law prohibits patients from emailing or faxing prescriptions directly to the pharmacy.
SPECIAL INSTRUCTIONS
Please include any special instructions regarding your order:
PLEASE READ, SIGN, & DATE
I certify that the information provided on this form is correct and authorize the release of all information to Homescripts, I authorize my
provider to send my prescription(s) to Homescripts, and to consult with a Homescripts pharmacist regarding any medication related
concerns. I AUTHORIZE HOMESCRIPTS PHARMACY TO SUBSTITUTE ANY FDA-APPROVED GENERIC DRUGS IN ALL CASES WHEN LEGALLY
PERMISSIBLE AND CONSISTENT WITH MY PROVIDER’S ORDERS AND MY BENEFIT PLAN.
Name (Printed):
Signature of Member or Legal Representative: Date:
Ask Your Provider to
Call or Fax Prescriptions To:
Yes, I would like to receive easy-open, non-safety caps. Initials:
Please email the completed, saved form to
customerservice@homescripts.com or fax to 877.396.5970.
Medication Name Strength
Toll-free: 1.888.239.7690
TTY: Please dial 711 for phone relay assistance
Customer Service Hours:
M-F 8am - 8pm EST, Sat 10am - 2pm EST
click to sign
signature
click to edit
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