New Patient Intake Form
Please complete the following questions to help us build your pharmacy profile.
If the patient is enrolled in an organization that provides care, please provide the name of the organization below and contact phone number.
Examples would be IDD group home, Home Health, Hospice, Personal Care Home, etc. This field is not intended to captured physician information.
Date of Birth
Home Phone Number
Cell Phone Number
Street Address Line 2
District of Columbia
Social Security Number
Used for verification of insurance and/or billing claims to federal or state programs.
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
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".
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.
Drag and drop files here
Choose a file
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 is the number that tells the pharmacy database which PBM should receive your claim.
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
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.
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?
Would you like your prescriptions to be automatically refilled when they are due?
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 in our local service area. Payment is due prior to the medication leaving the pharmacy. You will be contacted to provide credit card information. Patients enrolled in PakMyMeds has this fee waived. Delivery Policy is available at https://www.hartzells.com/delivery-map)
Pickup in the pharmacy
Ship via USPS ($12.95 fee. Payment is due prior to the medication leaving the pharmacy. You will be contacted to provide credit card information. Patients enrolled in PakMyMeds has this fee waived.)
Signature of Person Completing Form
Printed name of individual signing this form
Should be Empty: