Behind Every Rx is a Patient..


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Member Medication Questionnaire


Step2: Patient Profile

Please Complete the Patient Profile section below for EACH family Member who will be using Mail Order:

Complete this section only if you are requesting new Mail Order Prescription.

We will contact your prescriber on your behalf.

Please note:

  • Members will not be automatically enrolled in our Auto-Refill option, unless otherwise requested by member.
  • If including original prescriptions, please write your Member ID # and patient’s Date of Birth on each prescription
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*Please Select Payment Option

Please note that a member of Apogee’s Customer Service team will reach out to you via telephone to confirm address and chosen payment method prior to your first shipment. At that time, you will provide Apogee with your credit card or banking information, which will be stored in your profile for use on future copays.

*Step3: Responsible party payment agreement

Step4: Signature (I agree policy)


* Indicates required field.