Mail Service Enrollment

Filling out this form indicates all prescriptions at Atrius Health pharmacies will be mailed moving forward. There are limited exceptions to prescriptions that can be mailed and pharmacy staff will contact you if those apply.

* indicates a required field

Patient Name *:
Birth Date *: / /
E-Mail:
 
Address *:
City *:    State *:       Zip: *:   
Telephone *: () -
Best Time To Call:
Pharmacy Location *:
 
 
If you have not filled a recent prescription at Atrius Health pharmacies please include the following pharmacy insurance information from your prescription benefits:
BIN #:
PCN #:
Subscriber ID:
 
Would you like to sign up for auto-refills *? Yes    No
Do you currently fill prescriptions at an Atrius Health pharmacy *? Yes    No
 
Existing prescriptions at outside pharmacies can also be transferred to an Atrius Health pharmacy and enrolled in the free prescription mail service:
  Medication Name * Pharmacy * Pharmacy Phone No.
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