Secure Form

612 E 69th Street
Savannah, GA 31405
Tel No. 912-544-1501
Fax No. 912-544-1502

LTC and Resident Enrollment Form

Demographics

Patient Last Name:

Patient First Name:

Patient Date of Birth:

Gender:

Male

Female

SSN: ^?

Phone Number:

Please list any allergies

No allergies

Prescription Insurance Info:

Primary:

Cardholder ID #:

Rx BIN #:

Rx Group #:

PCN #:

Relationship to Cardholder:

Self

Spouse

Other

Secondary:

Cardholder ID #:

Rx BIN #:

Rx Group #:

PCN #:

Medicare ID #:

Facility Information

Facility Name:

Facility Tel No.:

Facility Address

Facility City

Facility State

Facility Zip

Facility Contact Person

Physician Information

Primary Care Physician First Name:

Primary Care Physician Last Name:

Phone:

Pharmacy Information

Previous Pharmacy:

Phone:

A photocopy of the insurance card (front and back) is optional to be included for the pharmacy to process insurance.

Insurance Card front:

Insurance Card back:

Responsible Party (statement mailed to this address):

Responsible Party First Name:

Responsible Party Last Name:

Phone:

Email:

Street

City

State

Zip

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