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Insurance Information

This form is provided in order for patients to complete insurance information that might not be clear or present on prescription forms faxed in from physician offices. If you are directed to this form please complete the information below. Note: many insurance companies issue a separate medical card and a prescription drug card . US Compounding needs information from the prescription drug card and not your medical card.

Patient First Name:
Patient Last Name:
Patient Date of Birth(MM-DD-YYYY):
The Patient Is:
Primary Insured’s Name (If the patient isn’t the primary insured):
First and Last
Address 1:
Address 2:
City:
State:
Zip Code:
Patient Email Address:
Phone Number:
Name of Insurance Company:
Phone Number of Insurance Company (Located on Your Rx Card):
Rx PCN#:
Rx BIN@* (Sometimes this is listed as IIN on your Rx card):
Rx Group#:
ID#*: