Prescription Mart Patient Enrollment Form

New Patient Enrollment Form
Insurance Information
BIN Number
6-digit number
BIN Number
Member ID Number
Group ID
PCN
Upload Insurance Card

Optional
Cancelof
Are you an EmpiRx Health Patient?
Please visit

myempirxhealth.com
Patient Contact Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Sex
Cell Phone
Enter cell phone for text notifications.Format: (000) 000-0000.
Would you like to receive text message updates about your prescriptions, shipments, and refill reminders?

By checking this box, you agree to receive SMS messages from Prescription Mart regarding prescription refill reminders, shipping or delivery updates, billing notifications, and customer care or support messages from Prescription Mart. Reply STOP to opt or HELP for help. Message and data rates may apply. Messaging frequency varies. See our Privacy Policy at https://www.prescriptionmartpharmacy.com/prescription-mart-privacy-policy and SMS Terms and Conditions at https://www.prescriptionmartpharmacy.com/sms-terms.
Home Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
E-mail
Primary Language

Other
Translation Services

Translation Services are available for limited English proficiency patients upon request. Prescription Readers are available for visually impaired patients upon request.
Drug Allergies?
Allergies

Other
Medical Conditions?
List Medical Conditions
Other Medications (including Over the Counter medications)
Think you'll need controlled substances?
Driver License Number
Upload Driver License

Optional
Cancelof
Are you a workers' compensation patient?
Date of Injury

MonthDayYear
2 digit month, 2 digit day, 4 digit year
How to Send Prescriptions
How will we get your prescriptions?

Other
Send us your prescription electronically.
- Ask your doctor to e-prescribe or fax a 3-month supply to our pharmacy.
We’ll take care of it from there.
- Our pharmacists will check that the medication prescribed is safe and effective for you. If we need more information, we’ll contact your doctor.
New Prescriptions?

Prescribers can send prescriptions using their electronic system to:

Prescription Mart

4144 Dowlen Rd

Beaumont TX, 77706

Phone: 800-713-1230

Fax: 409-866-1317
Current Pharmacy
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Prescriptions
Prescription Mart may substitute FDA-approved generic medications for brand name medications unless you or your prescriber specify otherwise. If you DO NOT want generic medications, you must provide specific instructions when speaking with our representatives. Refusal of generics may impact your copay.
Additional Comments
By signing below you agree that the information on this form is correct and authorize release of all information regarding your medical and prescription drug history and treatment to Prescription Mart Pharmacy. I hereby assign to the pharmacy any payment due pursuant to this transaction and future transactions and authorize payment directly to the pharmacy. The submission of this form, for you or any of your dependents, authorizes the release of all information to the Plan Sponsor, Administrator, or Underwriter.
Signature
Should be Empty:

New Patient Enrollment Form

Insurance Information

Patient Contact Information

Translation Services

How to Send Prescriptions