COVID-19 SUPPORT SERVICES ENROLLMENT FORM
Director
Collector
First Name
Middle Name
Last Name
Date of Birth
Gender
Please Select
Male
Female
Other
Phone Number
Home Phone
Email
Apartment / Space#
Facility Shelter Center
Street1
Street2
City
State
Zip Code
Insurance Carrier
Insurance Identification Number
Insurance Card Front
Insurance Card Back
DISCLAIMERS
Use of Data - We collect your personal information in order to fulfill your order, comply with the law, and assess your eligibility. Your data will not be sold to or shared with unaffliated third parties.
Electronic Communication Acknowledgment - I agree and consent to be contacted through the use of email and/or telephone calls and/or SMS text messages to my mobile phone number I have provided in conjunction with my account, including the use of automatic telephone dialing systems. I acknowledge that message and date rates may apply.
OPT IN to start receiving your Covid prevention and Support Services
I am enrolling in the COVID-19 home testing program. Which will continue until I opt out by contacting PerfectRx Pharmacy.
Your monthly HealthBox will be fulfilled by Mitry Pharmacy in Partnership with PerfectRX. This will be reflected in your Explanation of Benefits.
Interested in future mailed pharmacy medications.
Patient/Parents Name
First Name
Last Name
Is Patient
Image of ID of Patient/Parent
Signature
Clear Signature
Signed Date/Time
Cancel
Insurance Status
