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Patient Status
*
New Patient Enrollee
Existing Patient
First Name
*
Last Name
*
Date of Birth
*
+
SSN
*
🛈
Customer Type
*
Standard (Autopay)
Dual Eligible/LIS (Invoice)
Do you authorize SelectRx to set you up for autopay on a recurring basis using the payment method provided anytime prescriptions are filled? By signing up for autopay you agree and understand that your information will be securely stored on file for all future transactions on your account?
*
Yes
No
Do you authorize SelectRx to set you up for autopay on a recurring basis using the payment method provided anytime prescriptions are filled? By signing up for autopay you agree and understand that your information will be securely stored on file for all future transactions on your account?
*
Yes
No
Is the patient requesting to fill OTC (over-the-counter) meds?
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Yes
No
Primary Payment Method
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Credit Card
ACH
Payment Info
Credit Card Number
*
Expiration Date (mm/yy)
*
Account Type
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Checking
Savings
Bank Routing Number
*
Account Number
*
Credit Card Number
Card Expiration Date (mm/yy)
Account Type
Checking
Savings
Bank Routing Number
Account Number
Authorization
Confirm Credit Card and/or Bank Draft ACH Authorization
*
Do you authorize SelectRx to set you up for autopay and charge your credit card/bank draft on a recurring basis anytime prescriptions are filled? By signing up for autopay you agree and understand that your information will be securely stored on file and utilized for all future transactions on your account
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