Form 2 - ABP SOLUTIONS

HEALTHBOX
Formulario / Form

At PerfectRx Healthbox, our mission is to deliver accessible health and wellness solutions to your doorstep. We are dedicated to improving lives by providing a monthly box filled with carefully curated health and wellness items, including essential COVID tests, that empower individuals to take proactive steps towards a healthier, happier future. Our commitment to convenience, quality, and affordability ensures that everyone has the opportunity to embrace wellness.

How it works

SUBMIT YOUR INFORMATION

Getting started is easy. Simply complete our online form to provide us with your basic information.

VERIFY YOUR ELIGIBILITY

Allow us to verify your eligibility. This process is designed to be straightforward and confidential.

MONTHLY DELIVERY

Once your eligibility is confirmed, your PerfectRx Healthbox will be shipped directly to your doorstep every month at no cost to you.

Start now!

In order to help protect you and your family from COVID-19, PerfectRx Pharmacy is providing COVID-19 support services for vulnerable populations. As one part of this program, the Federal government and the state of Texas are providing access to easy to use, self-administered Antigen test kits if you are a Medicaid/Medicare member. These tests are being supplied FREE of charge and will be delivered directly to your home each month or can be picked up at our pharmacy location. Please complete the following information to receive your tests and more information related to COVID-19 treatment and prevention. Contact your healthcare provider to verify your eligibility or call us if you have any questions.

Patient Name*

First name

Last name

Date of Birth*

Gender*

Phone number*

Address*

Apartment, Lot or Condo #

City*

Zip Code*

State*

Email*

Insurance Carrier*

Insurance Identification Number:*

DISCLAIMERS*

Use of Data - We collect your personal information in order to fulfill your order, comply with the law, and assess your eligibility. Your data will not be sold to or shared with unaffliated third parties.

Electronic Communication Acknowledgment - I agree and consent to be contacted through the use of email and/or telephone calls and/or SMS text messages to my mobile phone number I have provided in conjunction with my account, including the use of automatic telephone dialing systems. I acknowledge that message and date rates may apply.

OPT IN to start receiving your Covid prevention and Support Services

By completing this form I am enrolling in the Medicaid/Medicare COVID-19 home testing offered to me as a Medicaid/ Medicare Member. Which will continue until I opt out by contacting PerfectRx Pharmacy. I confirm that I have read and agree to the above disclaimers.

Patient/Parents Name*

First name

Last name

Image of ID of Patient/Parent*

Image of Insurance Card of Patient (Front)*

Image of Insurance Card of Patient (Back)*

filing date*

Please type the characters*

This helps us prevent spam, thank you.

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