Med Manager New Patient Application

Secondary Contact(s)
If we cannot get ahold of you for any reason, who would likely be able to readily get in touch with you? (ex: spouse, family member, friend, or neighbor) We will NOT share your private information with this person by default.
Who should be our PRIMARY contact for regular communications regarding your medications and therapy? We will use these contacts in the order provided, and if you manage your own care simply type "self" in the name field.

	Name on Card	ID Number	Part A Effective Date	Part B Effective Date
Medicare (Red White and Blue Card)

Filling Preferences
Easy Open Caps (Medication bottles dispensed for you will not be child resistant.)

YesNo

Click to Enter Your Medication List (Make sure to include everything! Over the counter products, inhalers, injectables, etc. We have solutions for helping keep you on track with all your medications)

Choose the approximate time of day you take a dose. Medications you take at the same time will be packed together.

Click to to Upload a Picture of your Med List or Prescription Bottles
If you already have a current list of medications or would like to take pictures of your pill bottles instead of typing a list.

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Your Comments or Questions

Please let us know if there are other questions or concerns you have about using our program. We'll make sure when we reach out to cover these with you first!
I acknowledge that I have received and agree to the following items on the acknowledgement form:
• Notice of Privacy Practices
• Notice on Non-Child resistant packaging
• Patient Responsibilities
• Terms of Benefits
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Your Contact Information