Hartzell's Patient Intake Form

Insurance
Do you currently have health insurance (commercial coverage, Medicaid, Medicare, etc)?*

Yes - please complete information belowNo - 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.

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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

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 pharmacyI will scan hardcopy prescriptions with this formI 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

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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?

YesNo
Would you like your prescriptions to be automatically refilled when they are due?

YesNo
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 pharmacyShip 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

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Printed Name*
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New Patient Intake Form

Insurance

Pharmacy Insurance Information

Prescriptions

Order Preferences