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.
Email*
Local Pharmacy Name*
Local Pharmacy Phone Number*
Please enter a valid phone number.
Is the information listed above for the primary holder?*

YesNo
How did you hear about us?*

Online Content (Search Engine/Website/etc.)Social MediaPostcard MailerReferred by a current Synchrony/Trilogy employeeReferred by other family, friend, colleagueAccount ManagerOther
Referred By:*
Please Enter Name of Referrer?
Type of Referral

Home HealthIndependent LivingProvider GroupReferred ByOther
Trilogy IL or Elite IL?

Trilogy ILElite IL
Name of Referrer:
Primary Holder Information*
Communication Preference*

Text MessageEmailAutomated Call
Primary Care Physician:*
Primary Care Provider Phone Number*
Please enter a valid phone number.
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?*

YesNoI Don't Know
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: