Have Your Prescriptions Delivered To Your Door

Contact us to register or fill out the form below. We will update you as soon as your prescriptions(s) are processed and ready.

Location
Full Name*
Date of Birth*
MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code
Is this also your delivery address?
- Yes
- No
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Phone
Email
Attach a picture of your prescription card OR you can fill out the info below.
Max. file size: 256 MB.
Attach a picture of your prescription label OR you can fill out the info below.
Max. file size: 256 MB.
Insurance Company
Member ID#
RxBIN (6 digits)
RxPCN
RxGroup or GRP:
How would you like to receive your medication?
- Pickup
- Delivery
Your privacy is important to us. To protect the privacy of your individual health information (Protected Health Information, “PHI”) and as part of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), we are required to provide each patient with a Notice of Privacy Practices before or at the time of our healthcare services. We are also required to ask each patient to sign an acknowledgment form specifying receipt of this notice. We ask that you please read the Notice of Privacy Practices by clicking here and sign below as a receipt of our privacy notice. If you have any questions please contact our privacy officer at hipaa@apothecarygroup.com.
Consent*
* I accept Apothecary Group HIPAA Privacy Policy*
My signature below certifies that I have been provided with a written copy of APOTHECARY GROUP Notice of Privacy Practices. To read APOTHECARY GROUP HIPAA notice click here. To read our privacy policy click here.
Signature*
Date
MM slash DD slash YYYY

Have Your Prescriptions Delivered To Your Door

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