Onboarding Form - Synergen Rx | Pharmacy

Thank you for your submission. We look forward to being a part of your transplant journey and someone from our team will be reaching out shortly!

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Patient name as provided with Piedmont Hospital's System *

Date of Birth *

Phone number the patient would like to be contacted at *

Email the patient would like to be contacted at *

Please keep an eye out for a response via email shortly.

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Method of Contact *

Do you have Medicare (red, white, and Blue card) *

If yes selected: Please provide your Medicare ID: *

Do you have Medicaid *

If yes selected: Please provide your Medicaid ID: *

Do you have an Advantage plan? *

Do you have a supplemental plan? *

If you have commercial coverage or Medicare Part D coverage, Please provide your RxBin, RxPCN, RxGroup, and Member/Cardholder ID from your insurance card.

RxBin (6 digits):

RxPCN:

RxGroup:

Member ID:

Do you have additional prescription drug coverage: *

RxBin (6 digits):

RxPCN:

RxGroup:

Member ID:

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