Insurance Card Submission

Lopez Island Pharmacy (360)468-2616 Fax (360) 468-3825

Insurance ID Submission

rev:06/30/2020 HIPAA Compliant ver 1.0
You will be given a chance to take a photo of the front and back of your Insurance Card after answering a few basic questions. Thank you
Patients Name*

First NameMiddle NameLast NameSuffix
Sex*

MaleFemale
Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code