Language
English (US)
New Patient Intake Form
Please complete the following questions to help us build your pharmacy profile.
Patient Name
*
First Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Male
Female
Home Phone Number
*
Cell Phone Number
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
example@example.com
Social Security Number
*
Used for verification of insurance and/or billing claims to federal or state programs.
Race:
*
Not Specified
Asian
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Primary Care Provider:
The physician, CRNP, or PA that is your primary doctor
Please list any food or medication allergies that you have below.
*
Please list what food or medication you are allergic to and the reaction that occurs. If you do not have any allergies to food or medication, please type "NONE".
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Insurance
Do you currently have health insurance (commercial coverage, Medicaid, Medicare, etc)?
*
Yes - please complete information below
No - by choosing no you attest that you DO NOT have current coverage.
Please upload a photo of your PHARMACY and MEDICAL insurance card here. Front and back of card is needed.
Browse Files
Drag and drop files here
Choose a file
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Medicare Number (if applicable)
Medicare Number (MBI) has 11 alphanumeric characters and can be found on your Red, White, and Blue Medicare Card.
Medicaid Number - Medical Assistance ID Number (if applicable)
Please enter your Medicaid ID number including the card issue number.
Pharmacy Insurance Information
Health Insurance Plan Name
Pharmacy Member ID
Rx Group Number
RxBIN
RxBin is the number that tells the pharmacy database which PBM should receive your claim.
RxPCN
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Prescriptions
Please complete the following questions so we know how to receive your prescriptions.
Prescriptions will be provided to Hartzell's Pharmacy by which of the following methods. Please choose all that apply.
*
I will bring hardcopy prescriptions into the pharmacy
I will scan hardcopy prescriptions with this form
I will have my doctor send orders to the pharmacy (electronically prescribed or faxed to 610-264-3048)
Please transfer my prescriptions from another pharmacy
If you need us to transfer prescriptions from another pharmacy, please provide us: Pharmacy Name, Pharmacy Phone Number, and list the prescriptions you want to transfer red to Hartzell's Pharmacy
Prescription Secure File Upload
Browse Files
Drag and drop files here
Choose a file
If you have prescriptions please upload them. We will review if we can use them for filling or if we need to contact your prescriber.
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Order Preferences
Please complete the following questions so we may better assist you
Would you like to be notified that your orders are ready via text, email, and/or phone call?
Yes
No
Would you like your prescriptions to be automatically refilled when they are due?
Yes
No
Would you like to enroll in any of our pharmacy programs? More information on our programs can be found at https://www.hartzells.com/pharmacy-services
MyMedSync - Pharmacy Care Coordinator will call you to review your medications and coordinate them to a common date for pick up or delivery.
Hartzell's PakMyMeds - Strip packaging solution to help you stay organized
How would you like to receive your medication orders?
Delivery (No charge for prescriptions. Payment is due prior to the medication leaving the pharmacy. You will be prompted to provide credit card information.)
Pickup in the pharmacy
Ship via USPS ($10 fee. Payment is due prior to the medication leaving the pharmacy. You will be prompted to provide credit card information.)
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Credit Card Information
Name of Card Holder
First Name
Last Name
Credit Card Number
Credit Card Expiration Date
Please enter month and year (MMYY)
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Signature of Person Completing Form
Clear
Printed Name
*
Printed name of individual signing this form
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