Rx Input
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If you are already working with a Benefit Advisor, please enter their name below.
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First and Last Name
*
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Current Prescription Plan Provider (if any)
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Employer Group (if any)
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Phone Number (please use this format ##########)
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Phone Type
Mobile
Work
Home
Email Address
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Age
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Are you a member of EPIC?
Yes
No
I don't know
Zip code
*
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Preferred pharmacy
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Drug Name # 1
*
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Dosage #1
*
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Frequency #1 (1x per day, 2x, 3x...)
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Drug Name # 2
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Dosage #2
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Frequency #2
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Drug Name # 3
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Dosage #3
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Frequency #3
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Drug Name # 4
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Dosage #4
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Frequency #4
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Drug Name # 5
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Dosage #5
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Frequency #5
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Drug Name # 6
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Dosage #6
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Frequency #6
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Drug Name # 7
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Dosage #7
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Frequency #7
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Drug Name # 8
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Dosage #8
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Frequency #8
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Drug Name # 9
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Dosage #9
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Frequency #9
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Drug Name # 10
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Dosage #10
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Frequency #10
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Other thoughts or comments
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