TrueScripts Prescription Benefit Management

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844-257-1955

info@truescripts.com

New Member Intake Form

Member First Name

Member Last Name

Date of Birth

Physical Address (no P.O. Box)

Member Phone/Alt Phone

Email Address

How would you like to be contacted?

Best time to contact

Authorized/Alternative Contact

Specialty Meds

Next Fill Date

Employer

Date

Prescriber Name

Prescriber Address (City, State)

Prescriber Phone

Current Pharmacy

Current Pharmacy Phone

Free Text

Currently have a copay card? If Yes, fill out the next 4 fields.

Yes

BIN

PCN

Group

How many in household? (number of household members claimed on taxes)

Field label

Gross Yearly Income - Required

# in Household - 1

# in Household - 2

# in Household - 3

# in Household - 4

# in Household - 5

812-257-1955
844-257-1955 (Toll Free)

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844-257-1955

New Member Intake Form

812-257-1955844-257-1955 (Toll Free)

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Birthday Sparks

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812-257-1955
844-257-1955 (Toll Free)