MyRxManager - CIC Inc.

Prescription Medication Tracking Service

APPLICANT INFORMATION

Name:

Date of Birth:

4 Digit Pin #:

Phone:

Current address:

City:

State:

Zip:

PHYSICIAN INFORMATION

Current Primary Care Physician:

Address:

City:

State:

Zip:

Phone:

Email:

Fax:

List all prescriptions you are taking that were prescribed by this doctor (optional)

SPECIALIST:

OB/GYN:
Dermatologist:
Dentist:
Ophthalmologist (eye):
Cardiologist:
Oncologist (cancer):
Endocrinologist (diabetes):
Rheumatologist:
Neurologist:
Psychiatrist:
Other:

Address:

City:

State:

Zip:

Phone:

Email:

Fax:

List all prescriptions you are taking that were prescribed by this doctor (optional)

SPECIALIST:

OB/GYN:
Dermatologist:
Dentist:
Ophthalmologist (eye):
Cardiologist:
Oncologist (cancer):
Endocrinologist (diabetes):
Rheumatologist:
Neurologist:
Psychiatrist:
Other:

Address:

City:

State:

Zip:

Phone:

Email:

Fax:

List all prescriptions you are taking that were prescribed by this doctor (optional)

PRIMARY PHARMACY:

Address:

City:

State:

Zip:

Phone:

Email:

List any over the counter (OTC) medicines you currently take: (i.e. Aspirin, nasal sprays, etc.)

SECONDARY PHARMACY:

Address:

City:

State:

Zip:

Phone:

Email:

List any over the counter (OTC) medicines you currently take: (i.e. Aspirin, nasal sprays, etc.)

EMERGENCY CONTACT

Name of a relative or emergency contact person:

Address:

City:

State:

Zip:

Phone:

PAYMENT INFORMATION
Annual Fees:
Regular - $30
Seniors 55 years or older - $25
Children under 18 years or college students - $20
Optional: Please add $10 for an electronic Internet secured account and provide a 4-digit pin number)

SIGNATURE

I authorize Creative I C to act as my Rx manager for the purpose of obtaining, maintaining, monitoring and compiling confidential prescription medication. Electronic storage of this information in a password secured web based format will be provided as an optional service. I understand that no medical advice or consultation will be extended and this service is for tracking purposes only. The information provided on this form is accurate to the best of my knowledge. The applicant agrees to provide a print out of his/her current medications from the pharmacy and notify CIC when your medications change. CIC will issue a prescription card once a month upon receipt of a written change in the prescriptions displayed on the card when there is a change in information from the prior months prescription card. Four cards will be mailed or emailed to the member.

Signature of applicant:

Date:

Type verification image:

	7206 Hull Street Road Suite 200 Richmond, VA 23235 Office: (804) 674-8443 Fax: (804) 674-8332 myrxmanager@creativeic.com www.creativeic.com/myrxmanager A subsidiary of Creative Insurance Concepts, Inc. www.creativeic.com