New Patient Enrollment

New Patient Registration

Welcome to ahma Rx! Please provide the below information so we can get you your prescription as quickly as possible. Thanks!
**This form is not for Covid vaccine appointments**

Please use this form if you are interested in pre-registering for a Covid vaccine appointment.
Form Name
Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
E-mail
Please enter to receive tracking information for your rx delivery.
Cellphone Number:*
Please note we will be sending you updates of status and delivery
Home Phone Number:
Do you have any drug allergies?

YesNo
Please list any drug allergies:
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you want your medication delivered to your home address?

YesNo, different addressNo, I'll pick up at your pharmacy
Delivery Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the delivery address a doorman building?
Can the package be left at the doorstep/porch if no one is home?

YesNo
Which location will you pick up from?
Emergency Contact Opt-Out

I do not have an emergency contact or do not wish to provide one
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Do you have prescription insurance coverage?*

Yes, I will take a picture of my insurance cardYes, I will type in info belowNo, I will pay out of pocket
Please Take a Photo of the Front and Back of your Prescription Insurance Card (We will need the RX BIN, PCN, GRP, and ID.)
Take a Photo of the Front of Your Prescription (Rx) Insurance Card
Take a Photo of the Back of Your Prescription (Rx) Insurance Card
If you are unable to provide a photo of your insurance card, please provide the following:
RX BIN
RX PCN
RX ID NUMBER
RX GRP
I appoint ahma Rx to act as my representative in connection with any claim or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize ahma Rx to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim(s), appeal(s), grievance(s) or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to ahma Rx and that ahma Rx will not charge additional fees, beyond any copayments as dictated by my insurance, to be my representative.*

I Agree
Signature (Drag Finger or Mouse to Sign)*

Clear
Date

MonthDayYear
Date
Thanks for submitting your info! We will reach out to you shortly. Please expect a text message or call from us. If you have any questions, you can call/text us as 212-749-6626.
Should be Empty:

New Patient Registration