Economeds Prescription Order Form

  • Economeds Prescription Order Form

  • Welcome to Economeds!
    We’re here to make it easy and stress-free for you to get the medications you need—delivered right to your door, with no cost to you. By filling out the form below, you’re taking the first step toward receiving your prescriptions without any co-pays, coinsurance, or out-of-pocket costs.

    ✨ Before you begin:
    If possible, please have a copy of your prescription ready to upload.
    You’ll also need to sign our enrollment form if you haven't done so already.
    You'll be asked to fill it out later on in this form.

    We’re excited to help you get started—and we’re here if you need anything along the way!

  • Personal Information

  • Format: (000) 000-0000.
  • Birth Date*
     / /

  • Personal Information Continued

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  • Why do we need your photo ID?

    Since your medication is being shipped to you from abroad, customs may occasionally verify that a package is addressed to a real, intended recipient. Providing a photo ID simply helps confirm your identity so your order can move through the border process smoothly. It’s a standard step that helps prevent delays and ensures your medication arrives as quickly as possible.

  • Insurance Information

  • Please sign the following consent documents

  • Member Consent Form

    International Medication Sourcing Program


    I,             , hereby give my informed consent to participate in the International Medication Sourcing Program (the "Program") provided by Economeds LLC as described below.

    1. Authorization to Share Information
    1.1. I authorize my employee benefit plan (the “Plan”) to share my information with Economeds, LLC to facilitate my access to the Program. The purpose of the Program is to facilitate the importation of my prescription drugs for my own personal use from international sources.

    2. Program Understanding and Consent
    2.1. I am at least 18 years of age, and a U.S. citizen, and a lawful resident of the state into which my medications are intended to be imported. I have the capacity to make fully informed decisions about my medical treatment.
    2.2. I am entering the Program solely for the purpose of obtaining prescription medication using a valid prescription written by my health care provider for my own personal use.
    2.3. I understand that the Program is designed to source and import my prescribed medications on my behalf from international suppliers at potentially lower costs than domestic sources, whenever it is cost-effective.
    2.4. I may withdraw my participation in this Program at any time by doing so in writing to info@economeds.co.
    2.5. I expressly consent to and prefer that my medications be sourced from international suppliers when available.
    2.6. I understand that the Program will determine, at its discretion, whether my medications will be sourced domestically or internationally based on availability and cost-effectiveness.
    2.7. I understand that I may decline to enter the Program, or I may withdraw my participation from the Program, without detrimental effect to my health care or detrimental impact to my participation with my Plan, other than those related to the cessation of the Program and the Program’s benefits.

    3. Importation Liability
    3.1. I accept and assume full responsibility and liability for the importation of my prescribed medications through this Program.
    3.2. I understand that this assumption of liability is limited strictly to medications that have been legitimately prescribed to me by a licensed healthcare provider.
    3.3. I acknowledge that I am not assuming any liability for medications not prescribed to me or for any other person's medications.
    4. Risks and Benefits
    4.1. I understand that sourcing medications internationally may involve certain risks, including:
    4.1.1. Potential delays in receiving medications
    4.1.2. Possible differences in packaging or labeling
    4.1.3. Potential scrutiny by customs or regulatory authorities
    4.2. I acknowledge that the primary benefit of participating in this Program is the potential for significant cost savings on my prescribed medications.

    5. Voluntary Participation
    5.1. I confirm that my participation in this Program is entirely voluntary.
    5.2. I understand that I can withdraw my consent and discontinue participation in the Program at any time by giving written notice of my withdrawal.

    6. No Guarantee - I understand that while the Program will make try to source my medications at lower costs, there is no guarantee that my prescriptions will be available through international sources or that cost savings will always be achieved.

    7. Authorization to Contact Healthcare Provider
    7.1. I authorize the Program to contact my healthcare provider(s) directly for the following purposes:
    7.1.1. To update my preferred pharmacy information
    7.1.2. To obtain personal health information as it relates to medications I have been prescribed
    7.2. I understand that this authorization allows the Program to communicate with my healthcare provider(s) on my behalf to facilitate the process of sourcing my medications from international sources.
    7.3. I acknowledge that this authorization extends to all healthcare providers who have prescribed medications for me in the past or in the future.

    8. Consent for Electronic Communication
    8.1. I understand and agree that my prescription information and Health Information may be communicated
    via a HIPAA-compliant Slack messenger chat, instead of through a formal prescription transfer process, if the situation calls for this type of communication.
    8.2. I acknowledge that while Slack messenger is described as HIPAA-compliant, electronic communication carries inherent security risks.
    8.3. I consent to the use of Slack messenger for transmitting my information when deemed necessary by the Program, understanding that this method may be used to expedite the process of sourcing my medications.
    8.4. I release the Program, my healthcare providers, and all involved parties from any liability related to the use of Slack messenger for communicating my health information, provided they maintain reasonable security measures.

    9. Indemnification
    9.1. I agree to indemnify and hold harmless my pharmacy, Empire Healthcare Benefits, Economeds LLC, and their respective employees, agents, and affiliates from any claims, damages, or liabilities arising from the importation of pharmaceuticals for my own personal use, and from my participation in this Program, except in cases of gross negligence.

    By signing below, I certify that I have read, understood, and agree to all the terms and conditions outlined in this consent
    form. I have had the opportunity to ask questions and have had them answered to my satisfaction.

    Signature:       

    Print Name:         
    Date:   Pick a Date      



    HIPAA Authorization to Use and Disclose Protected Health Information


    1. I hereby authorize my employer,       (the “Plan”) to disclose my
    protected health information (“PHI”) in the manner described below to Economeds, LLC (“Business Associate”).
    2. The PHI may be used and/or disclosed to facilitate my participation in my Plan’s International Medication Sourcing Program (the “Program”), including the potential re-disclosure of my PHI to any pharmacy selected to provide my personal-use medication. This information may include any and all of my PHI, including my
    prescription information and my individually identifiable health information or other medical records, including any information governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and records or communications governed by the Mental Health and Developmental Disabilities Confidentiality Act. The purpose of the Program is to facilitate the importation of my prescription drugs for my own personal use from international sources as allowed by law.
    3. This authorization shall remain in effect for the lesser of one year from the date signed below or until I withdraw my participation in the program.
    4. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this form.
    5. I understand that, as set forth in the notice of privacy practices, I have the right to revoke this authorization, in writing, at any time, except to the extent that the Plan or Business Associate has acted in reliance upon it, by sending written notification to: info@economeds.co.
    6. I understand that I have the right to refuse to sign this authorization without detrimental effect to my health care or impact to my participation with my Plan, other than those related to the cessation of the Program.
    7. I understand that PHI used or disclosed pursuant to this authorization may be redisclosed by the recipient and its confidentiality may no longer be protected by federal or state law.

         

          

    Pick a Date   

  • Program Enrollment

    Member Consent FormInternational Medication Sourcing Program

  • SIGNATORY INFORMATION

    Please complete one of the following. If you are signing on behalf of a minor or legally incapacitated adult, complete both Part A and Part B. If you are the Member signing for yourself, complete Part A only.
    Part A – Member (the person receiving medications)
    Member Full Name: 
      *   *
    Date of Birth:
        Pick a Date*   

    Part B – Parent or Legal Guardian (complete only if signing on behalf of the Member)
    Parent/Guardian Full Name:
                 
    Relationship to Member: 
               
    Legal Authority Documentation:


    By signing this form, the Parent/Legal Guardian certifies that they have full legal authority to consent on behalf of the Member, that such authority has not been revoked or limited, and agrees to notify the Program Administrator immediately if their legal authority changes.

    DEFINITIONS
    As used throughout this form: "Member" means the individual identified in Part A above who will receive medications through the Program. "Signatory" means the individual signing this form — either the Member personally, or the Member's parent/legal guardian. Where this form uses "I," "me," or "my," these terms refer to the Signatory acting in their own right or, where applicable, on behalf of the Member.
    ---
    The Signatory identified above hereby gives informed consent for the Member to participate in the International Medication Sourcing Program (the "Program") provided by Economeds LLC and its affiliates and assigns (collectively, the "Program Administrator") as described below.

    1. Authorization to Share Information
    a. The Signatory authorizes the Member's employee benefit plan (the "Plan") to share the Member's information with Economeds, LLC to facilitate the Member's access to the Program. The purpose of the Program is to facilitate the importation of the Member's prescription drugs for the Member's own personal use from international sources.
    2. Program Understanding and Consent
    a. The Signatory represents that: (i) if signing as the Member, they are at least 18 years of age, a U.S. citizen, and a lawful resident of the state into which medications are intended to be imported, and have the capacity to make fully informed decisions about their own medical treatment; or (ii) if signing as a parent or legal guardian, they have full legal authority to consent on behalf of the Member and the Member is a lawful resident of the state into which medications are intended to be imported.
    b. The Member is entering the Program solely for the purpose of obtaining prescription medication using a valid prescription written by the Member's health care provider for the Member's own personal use.
    c. The Signatory understands that the Program is designed to source and import the Member's prescribed medications on the Member's behalf from international suppliers at potentially lower costs than domestic sources, whenever it is cost-effective.
    d. The Signatory may withdraw the Member's participation in this Program at any time by doing so in writing to info@economeds.co.
    e. The Signatory expressly consents to and prefers that the Member's medications be sourced from international suppliers when available.
    f. The Signatory understands that the Program will determine, at its discretion, whether the Member's medications will be sourced domestically or internationally based on availability and cost-effectiveness.
    g. The Signatory understands that the Member may decline to enter the Program, or participation may be withdrawn at any time, without detrimental effect to the Member's health care or detrimental impact to the Member's participation with the Plan, other than those related to the cessation of the Program and the Program's benefits.
    3. Importation Liability
    a. The Signatory accepts and assumes full responsibility and liability for the importation of the Member's prescribed medications through this Program.
    b. The Signatory understands that this assumption of liability is limited strictly to medications that have been legitimately prescribed to the Member by a licensed healthcare provider.
    c. The Signatory acknowledges that they are not assuming any liability for medications not prescribed to the Member or for any other person's medications.
    4. Risks and Benefits
    a. The Signatory understands that sourcing medications internationally may involve certain risks, including:

    i. Potential delays in receiving medications

    ii. Possible differences in packaging or labeling

    iii. Potential scrutiny by customs or regulatory authorities

    b. The Signatory acknowledges that the primary benefit of participating in this Program is the potential for significant cost savings on the Member's prescribed medications.
    5. Voluntary Participation
    a. The Signatory confirms that the Member's participation in this Program is entirely voluntary.
    b. The Signatory understands that consent may be withdrawn and the Member's participation discontinued at any time by giving written notice of withdrawal.
    6. No Guarantee
    a. The Signatory understands that while the Program will endeavor to source the Member's medications at lower costs, there is no guarantee that the Member's prescriptions will be available through international sources or that cost savings will always be achieved.
    7. Authorization to Contact Healthcare Provider
    a. The Signatory authorizes the Program to contact the Member's healthcare provider(s) directly for the following purposes:

    i. To update the Member's preferred pharmacy information

    ii. To obtain personal health information as it relates to medications prescribed to the Member

    b. The Signatory understands that this authorization allows the Program to communicate with the Member's healthcare provider(s) on the Member's behalf to facilitate the process of sourcing the Member's medications from international sources.
    c. The Signatory acknowledges that this authorization extends to all healthcare providers who have prescribed medications for the Member in the past or may do so in the future.
    8. Consent for Electronic Communication
    a. The Signatory understands and agrees that the Member's prescription information and Health Information may be communicated via a HIPAA-compliant Slack messenger chat, instead of through a formal prescription transfer process, if the situation calls for this type of communication.
    b. The Signatory acknowledges that while Slack messenger is described as HIPAA-compliant, electronic communication carries inherent security risks.
    c. The Signatory consents to the use of Slack messenger for transmitting the Member's information when deemed necessary by the Program, understanding that this method may be used to expedite the process of sourcing the Member's medications.
    d. The Signatory releases the Program, the Member's healthcare providers, and all involved parties from any liability related to the use of Slack messenger for communicating the Member's health information, provided they maintain reasonable security measures.
    9. Indemnification
    a. The Signatory agrees to indemnify and hold harmless the Member's pharmacy, the Plan, Economeds LLC, and their respective employees, agents, and affiliates from any claims, damages, or liabilities arising from the importation of pharmaceuticals for the Member's own personal use, and from the Member's participation in this Program, except in cases of gross negligence.

    By signing below, the Signatory certifies that they have read, understood, and agree to all the terms and conditions outlined in this consent form, and — if signing as a parent or legal guardian — that they have full legal authority to do so on behalf of the Member. The Signatory has had the opportunity to ask questions and has had them answered to their satisfaction.


    Signature*:   *       Date*:   Pick a Date*   
    Print Name*:    *   *   
    Capacity: 
          *      



    HIPAA Authorization to Use and Disclose Protected Health Information


    1. The Signatory hereby authorizes the Member's health plan,   *  (the "Plan") to disclose the Member's protected health information ("PHI") in the manner described below to Economeds, LLC and its affiliates and assigns (collectively, the "Business Associate").
    2. The PHI may be used and/or disclosed to facilitate the Member's participation in the Plan's International Medication Sourcing Program (the "Program"), including the potential re-disclosure of the Member's PHI to any pharmacy selected to provide personal-use medication. This information may include any and all of the Member's PHI, including prescription information and individually identifiable health information or other medical records, including any information governed by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and records or communications governed by the Mental Health and Developmental Disabilities Confidentiality Act. Economeds, LLC will require its affiliates and assigns to possess, use, and disclose with at least the same level of privacy as Economeds, LLC. The purpose of the Program is to facilitate the importation of the Member's prescription drugs for the Member's own personal use from international sources as allowed by law.
    3. This authorization shall remain in effect for the lesser of one year from the date signed below or until the Member's participation in the Program is withdrawn.
    4. The Signatory understands that the Member's treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether this form is signed.
    5. The Signatory understands that, as set forth in the notice of privacy practices, this authorization may be revoked in writing at any time, except to the extent that the Plan or Business Associate has acted in reliance upon it, by sending written notification to: info@economeds.co.
    6. The Signatory understands that the Member has the right to refuse to sign this authorization without detrimental effect to the Member's health care or impact to the Member's participation with the Plan, other than those related to the cessation of the Program.
    7. The Signatory understands that PHI used or disclosed pursuant to this authorization may be redisclosed by the recipient and its confidentiality may no longer be protected by federal or state law.


    Signature*:    *       
    Date*:    Pick a Date*   
    Printed Name*:    *   *   

    Capacity: 
          *      

    If signing as Parent/Legal Guardian, also complete:
    Parent/Guardian Printed Name:       
    Relationship to Member:       

  • Prescription Information

    We can’t fill your order until we receive your prescription. Your prescriber can email it directly to us at prescriptions@economeds.co, or efax it to us at 539-204-5790.
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  • Physician Information

    This information may be used to contact your physician regarding your prescription
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Shipping Information

    Where would you like your medications shipped to?
  • Should be Empty: