Update your information

Now as simple as uploading a couple photos

Just take photos of your RX or Medicare card (front and back). Next, enter your basic info on the form below, choose RX or Medicare to update and select ‘upload photos’. Submit. Done! No typing all the info from your card.

Your full name is required and must match our records exactly.

Please update other fields where information has changed. Where there is no change, you can leave the field blank.

* = required field

Name(Required)

First Last

Email(Required)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Drug allergies

Primary care physician

Would you like to update your RX insurance plan or Medicare details?(Required)

RX plan information

Medicare details

No. Just my personal info above.

How will you provide the information?

I want to upload photos of my card

I want to use the online form

Upload photos of your RX or Medicare card

Please include BOTH front and back of your card.

Files

Drop files here or

Accepted file types: jpg, png, Max. file size: 4 MB, Max. files: 2.

Upload photos of front and back of your card. Acceptable file formats are .jpg and .png. Maximum file size per image: 4MB.

Your insurance info

This information is found on the prescription card you received from your insurance provider.

Insurance carrier(Required)

PCN#(Required)

BIN#(Required)

Group #(Required)

Member ID(Required)

Your Medicare information

Enter information from the new Medicare cards only.

The new Medicare number is made up of letters and digits and looks similar to this:
1EG4-TE5-MK72

DO NOT enter a Social Security number.

Medicare number

Medicare coverage

Part A

Part B

Both Part A and Part B

We will treat your information in accordance with our Privacy Policy.

Name

This field is for validation purposes and should be left unchanged.