New Member Registration And Prescription Order Form
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1
2New Member Registration and Prescription Order Form
If you’d like to register online, or for more information, visit .
If you have questions, call RightSourceRx at 1-800-379-0092 (TTY 1-877-833-4486). Customer Care
Representatives are available Monday - Friday, 8 a.m. - 11 p.m., and Saturday, 8 a.m. - 6:30 p.m Eastern Time.
Instructions:
-Print all information clearly in CAPITAL LETTERS using BLUE or BLACK ink.
-Fill in the applicable circles completely. ( )
STEP 1 - Member Information
Member ID (found on Humana ID card)
Date of Birth
Gender
Male
-
M M
D D
/
Y Y Y Y
/
Female
First Name
Last Name
M.I.
Street Number
Street Name
Apt/Suite #
City
State
ZIP Code
-
Daytime Phone
Evening Phone
-
-
-
-
RightSourceRx will send you alerts about your order if e-mail address is given.
E-mail Address (optional)
Language preference for communications:
English
Spanish
STEP 2 - Dependent Information - spouse, child, etc - if applicable
(For additional dependents, please complete another form.)
Member ID (found on Humana ID card)
Date of Birth
Gender
-
Male
M M
D D
Y Y Y Y
/
/
Female
First Name
Last Name
M.I.
RightSourceRx will send you alerts about your order if e-mail address is given.
E-mail Address (optional)
Language preference for communications:
English
Spanish
STEP 3 - Please complete shipping address below if different from Member address above.
Street Number
Street Name
Apt/Suite #
City
State
ZIP Code
-
GHC20125APP1109
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