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

* = Required fields

Patient Name

Patient First Name  *

Patient Last Name  *

Employer of Insured  *   

Primary Insured First Name & Last Name (if different from above)

Insured First Name

Insured Last Name

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.

Member ID Number  *

Bin Number  *

Rx Group Number  *

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  *   

Loading…

Gender  *

Pronouns that you use

Cell Phone Number  *		Send notifications by text message   Yes
Home Phone Number  *		Notify me by phone call   Yes
Primary Email Address (personal email recommended)  *		Send notifications by email   Yes
Secondary Email Address

Patient Mailing Address  *   

(Please be aware that work email addresses could be blocked)

City  *   

State  *

Zip Code  *

---

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.

Anoro Ellipta Apidra Apidra Solostar Arnuity Ellipta Atripla Basaglar Kwikpen Biktarvy Breo Ellipta Brilinta Combivent Respimat Descovy Dulera Eliquis Farxiga Fiasp Ibrance Incruse Invokamet Invokana Isentress Janumet Janumet XR Januvia Jardiance Juluca Multaq Myrbetriq Omnaris Ozempic Prezcobix Qvar Rexulti Rybelsus Silenor Spiriva Respimat Sprycel Tivicay Toujeo Solostar Tradjenta Trelegy Ellipta Trintellix Trulance Trulicity Tudorza Victoza Xarelto

Please select the Specialty Drug(s) you are prescribed.

Actemra Adempas Afinitor Aubagio Avonex Benlysta Cimzia Cosentyx Dupixent Enbrel Firazyr Gilenya Haegarda Humira (biosimilars) Humira CF (biosimilars) Kuvan Norditropin AQ Orencia Otezla Pulmozyme Rebif Revlimid Rinvoq Simponi Skyrizi Stelara Strensiq Sutent Tagrisso Taltz Tobi Podhaler Tremfya Tyvaso Vemlidy Vumerity Xeljanz Xeljanz XR Xolair Zelboraf

  OTHER (my drug is not listed)

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  *   

Please check box to grant permission to contact the prescriber on your behalf regarding your medication(s).

---

Is Patient a Smoker or Non-Smoker?  *   

Non-Smoker Smoker

Are you allergic to Latex?  *   

Yes No

Are you a Veteran?  *   

Yes No

---

Questions? Need help? Email:  help@veracity-rx.com

Submit Form

Your information is saved directly to VeracityRx in a secured format.