• Member Information
• Enroll or opt out
• Sign & submit

FORT

Member first name

Member last name

Member date of birth

Medicare ID

Are you interested in participating in a Comprehensive Medication Review with a plan pharmacist?

Yes, I am interested in participating.

No, please opt me out of the program.

A member of the Pharmacy team will follow-up with the contact information provided. During this call, a Scripius pharmacist will review your medications, provide suggestions on how to minimize side effects, and offer ways to simplify your medication routine.
 

Phone number

Best day to call

Preferred call time

Morning Afternoon Evening

Signature

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