Home About MedEx Pack Sign Up About MedEx Direct Benefits/Services
  1.877.899.6337  
 
  Enrollment Options  
  To enroll in the MedEx Pack:  
 
       1. Sign Up by PHONE
           Call our pharmacy at 1.877.899.6337.

 
       2. Sign Up ONLINE
          Fill in the Enrollment Form below
          and click SUBMIT.
3. Sign Up by MAIL
    Click Here to print a copy of the Enrollment Form. Send
    completed form to: MedEx Direct, 13201 Stephens Rd.,
    Suite B, Warren, Michigan 48089
4. Sign Up by FAX
    Click Here to print a copy of the Enrollment Form.
    Fax completed form to 1.877.899.6360.
 
Patient Information
MedEx Direct is committed to ensuring that we have accurate information for each patient. We need your help to meet this goal. Please fill out the following:
*Indicates Required Information
*Patient's Name
*Phone (ex. xxx-xxx-xxxx)
*Address
*City
State
*Zip
Email
Confirm Email
*Date of Birth (ex. xx/xx/xxxx)
*Gender   Male Female
   
Drug Allergies
(Click all that apply)
Penicillin
Aspirin
Sulfa
Codeine
Erythromycin
Tetracycline
 
No Known Drug Allergies
Other (Please Specify)
 
 
Responsible Party / Caregiver Information
Responsible Party/Caregiver is an individual who is either helping to manage health care or finances for a patient. He/she is someone who is directly involved in making decisions and/or payments.
Caregiver's Name
Relationship
Phone (ex. xxx-xxx-xxxx)
Address
City
State
Zip
   
Prescription Insurance Information
*Prescription Insurance
Insurance Phone
*ID / Member #
BIN #
RX Group
PCN
 
Medication Information
Current Pharmacy
Pharmacy Phone (ex. xxx-xxx-xxxx)
 
 
 
*Initial
Acknowledgment of Receipt of the Notice of Privacy Practice
Federal regulations require that MedEx Direct obtain proof that customers have received the Notice of Privacy Practices. My signature indicates only that I have received a copy of MedEx Direct’s Notice of Privacy Practice,
not that I have read it or agree with its contents.
 
*Initial
Notice of Non-Child Resistant Packaging
Regulations require that we dispense all oral medications in “child-proof” containers or systems. The MedEx Pack strips and dispenser are NOT child resistant. By signing, you indicate that you are requesting a waiver of this regulation and that all medications be dispensed in a “non-child-proof” container or system until further written notice.
 
*Initial
MedEx Pack Packaging Responsibilities
I understand that receiving the MedEx Pack requires me to be involved in managing my medications. I will notify pharmacy staff members within an appropriate time period when my medications are changed, discontinued or when a new medication will start. I will work with MedEx Direct to determine the most appropriate start date to begin using the MedEx Pack to minimize wasting drugs that I currently have in my possession and to minimize insurance charges.
 
*Initial
Terms of Benefits
The signed resident/patient and/or legally responsible representative authorizes all providers of medical/drug benefits to the resident to pay MedEx Direct directly for any benefits that the resident is entitled to for the services and products provided by MedEx Direct; authorizes MedEx Direct to release medical information related to the patient’s care to the patient’s providers of medical or drug benefits so that MedEx Direct can receive payment; and understands and agrees that, where permitted by law, he or she is personally responsible to pay MedEx Direct for any services or products that are not paid for by the provider of any available medical or drug benefits.
   
*Signature of Patient or Responsible Party    *Date (ex. xx/xx/xxxx)
  (type name here)    
 
 
 
 
 
MedEx Direct, LLC | 13201 Stephens Rd., Suite B | Warren, MI 48089 | Phone: 1.877.899.6337 | Fax: 1.877.899.6360
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