SynchronyRx@HOME Request for Information Form

SynchronyRx@HOME Request for Information Form
Thank you for accessing the SynchronyRx@HOME request for information form. This form is designed to collect the necessary data in order for SynchronyRx@HOME to efficiently and effectively service your maintenance and specialty medication needs.

Please note that you will be required to enter the following information: Date of Birth, Primary Care Physician, List of Current Medications and Doses, Medication Allergies, and Health Conditions.

First Name
Last Name
Home Address
Home Address Line 2
City
State
ZIP/Postal
Birth Date
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
Local Pharmacy Name
Local Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the information listed above for the primary holder?
How did you hear about us?

Other
Referred By:
Please Enter Name of Referrer?
Type of Referral

Other
Trilogy IL or Elite IL?
Name of Referrer:
Primary Holder Information
Communication Preference
Primary Care Physician:
Primary Care Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please enter any medication allergies. If no allergies, leave field blank:
Please enter any health conditions. If no health conditions, leave field blank:
Please enter any medications you are currently taking. If no active medications, leave field blank:
Are there dependents listed on your account?
Dependent Information (If Email, Phone, Mailing Address is Same as Primary, Enter Same)
Please enter any medication allergies of above listed dependents. If no allergies, leave field blank:
Include Name(s) of Dependent
Please enter any health conditions of above listed dependents. If no health conditions, leave field blank:
Include Name(s) of Dependent
Please enter any medications the above listed dependents are currently taking. If no active medications, leave field blank:
Include Name(s) of Dependent
Should be Empty: