Form Downloads

Download Forms

        Fill out the appropriate form below and Fax to 1-800-658-2168 or Mail your completed form to:
        8605 Allisonville Rd. / Ste. 325, Indianapolis, IN 46250. If you have questions, pertaining to any of our forms,
        contact our Member Support Center by phone. Same number 1-800-658-2618 or you can email your
        questions to at office@myrxbenefitcard.com. We will be more than happy to address any concerns you have.

Patient Health Profile - This form is used to collect a brief health history and current health conditions for our health professionals and pharmacists to reference. This form is a requirement for any Mail Order.

Patient Authorization and Consent Form - This form explains our customer agreement policies and procedures as well as the patient's rights when ordering medications. This form is a requirement for any Mail Order.

Medication Order Form - This is the order form used to place an initial order of any medication. You must mail an authorized prescription signed by a licensed physician to our offices in order for us to fill any order. We recommend that you request a 90 day prescription with 3 refills.

Refill Order Form - This is the order form to use when ordering refills from an existing prescription, our pharmacy has on file.

Referral Form - This is form used for you to receive credit for the referral of a new client to RxBenefitCard. Call and ask about our referral program!