Household Member Info

Pharmacy Name	Pharmacy Address	Pharmacy City	Pharmacy State	Pharmacy Zip Code	Pharmacy County	Pharmacy Phone Number
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ALERT UPCOMING MEDICAL CARE for

In your orientation packet, we indicated how important it is for you to Pre-Alert us of anything major coming up (things that will require Inpatient or Outpatient Hospital Care, Outpatient Surgery, MRI, or ongoing Physical Therapies in the next 12 months). We use that information to coordinate Reinsurance. This helps us keep costs down long term.

Please describe anything that you anticipate might be going on over the next 12 months so that we can get a head start. By letting us know early we are able to award a helper to streamline the reimbursement speed for your family.

Does anyone in your family have any intended Major Procedures or Therapies likely in the next 12 months?

Does have any intended Major Procedures or Therapies likely in the next 12 months?

No
Yes

has no intended procedure in the next 12 months
will have the following procedure/test in the next 12 months (please describe)

Procedure Description (If multiple procedures list each Procedure separated by a COMMA)

Procedure Date ( If multiple procedures listed show the dates in the same order separated by a COMMA)

Procedure Provider ( If multiple procedures listed show each corresponding provider in the same order separated by a COMMA)

ALERT ONGOING PRESCRIPTIONS for

Date of Birth(mm/dd/yyyy)
Last 4 digit of your SSN:
Email:
Phone: