Dashboard Orders Addresses Account details New Patient Transfer a Prescrition Refill Prescrition Insurance Information Doctor Office "*" indicates required fields Name* First Name Last Name Customer ID ( ID or member number on card)*Rx Bin ( Rx Bin written on card either on front or back)*Group ( Group number written on card either on front or back)Insurance PhoneCustomer service number or pharmacist numberInsurance Card UploadUpload (Upload picture of card front and back via smart phone or desktop) Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, Max. file size: 256 MB, Max. files: 2.
