Health Insurance Intake Form

Share your coverage so our team can verify your benefits before filling your prescription. Questions? Call (813) 515-7918.

Patient Information

Patient full name *

Date of birth *

Phone # *

Email *

Street address *

Unit/Suite #

City *

State *

Zip *

Preferred contact

Primary Insurance

Insurance company *

Plan name

Plan type

Member ID # *

Group #

Effective date

Rx BIN

Rx PCN

Rx Group

Insurance phone # (back of card)

Secondary Insurance

I have secondary insurance

Medicare / Medicaid

Medicare # (MBI)

Medicaid #

Insurance Card Photos

Upload front of cardUpload back of card

Authorization

Initials *

I confirm the information above is accurate. I authorize Salhab Specialty Pharmacy to verify my insurance benefits, submit claims to my insurance on my behalf, and release information necessary to process those claims. I understand I am responsible for any copays, deductibles, or charges not covered by my plan.

Signature *

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Date