Prescription Benefit Card Enrollment Form

To Enroll, Please Complete The Form Below.  Each new member will receive a card.

Primary:

First Name:

MI:

Last Name:

Your Sex: Male Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Ship To Address:    

City:

State: 

Zip Code:

Phone:

Email:  

Enrollment Information For Additional Individuals To Be Covered.

Spouse:

First Name:

MI:  

Last Name:

Sex:  Male  Female (Select One) 

Birth Date:  / /  (xx/xx/xxxx)

Dependent 1:

First Name:

MI:  

Last Name:

Sex:  Male  Female (Select One)    

Birth Date:  / /  (xx/xx/xxxx)

Dependent 2:

First Name:  

MI:  

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Dependent 3:

First Name:  

MI:  

Last Name:  

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Dependent 4:

First Name:

MI:  

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Dependent 5:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Dependent 6:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Dependent 7:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Dependent 8:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One) 

Birth Date:  / /  (xx/xx/xxxx)

Dependent 9:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Dependent 10:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)