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Email: help@veracity-rx.com
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Please complete the following information. You will receive a follow-up notification from a VeracityRx Associate within 24-48 business hours to discuss your case.
Patient Information Profile
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* = Required fields
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Patient Name
Employer of Insured
*
Primary Insured First Name & Last Name (if different from above)
Please provide details of your primary drug insurance below.
If you have not received your insurance card, or aren't sure what to enter, please put N/A or UNKNOWN in each field.
If you have a current manufacturer copay assistance card, please provide the BIN, PCN, CARD ID, and GROUP #.
Does the Patient have any other drug coverage (i.e., Medicaid, secondary coverage)?
*
Are you in a high deductible healthcare plan with a Health Savings Account (HSA)?
*
Yes
No
Patient Date of Birth
*
Gender
*
Patient Mailing Address
*
(Please be aware that work email addresses could be blocked)
City
*
Below are two separate drug lists. Please review both lists and select the drug(s) you are currently prescribed. If your drug(s) are not present on either list, please provide the name of each prescription medication not listed.
Please select the Personal Importation Drug(s) you are prescribed.
Please select the Specialty Drug(s) you are prescribed.
If your drug(s) is not listed, please provide the drug(s) name:
If you chose a "Specialty" drug or selected "Other", please select your household size and income range below:
Number of people living in Patient Household
*
Household Annual Income Range (USD)
*
Please include the strength of the drug(s) you are prescribed.
*
This drug(s) is used to treat what condition?
*
List any Allergic Reaction you may have had and the name of the drug which caused the reaction.
*
Doctor (prescriber) name for the drug(s) above
*
Doctor (prescriber) phone number for the drug(s) listed above
*
Doctor (prescriber) fax number for the drug(s) listed above
*
Please list any other drugs you are currently taking
*
Is Patient a Smoker or Non-Smoker?
*
No fumador
Fumador
Are you allergic to Latex?
*
Yes
No
Are you a Veteran?
*
Yes
No
Questions? Need help? Email:
help@veracity-rx.com
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Your information is saved directly to VeracityRx in a secured format.
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Rev 1.0.1
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© 2025 Veracity Benefits, LLC. All Rights Reserved.
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