Email sign-up

Receive FREE e-mail newsletters about healthy living, events, product offers, our pharmacy and more.
Home Delivery - Enrollment

Please read the following directions thoroughly before submitting your Home Delivery form online.


You may also download this form HERE to print and mail it in.


If you have not used HomeTown Pharmacy's Home Delivery Service in the past, please fill out the following form. You will be able to order your refill online or by telephone within 2 business days of submission.


If you are already a Home Delivery customer, YOU DO NOT NEED TO FILL OUT THIS FORM TO USE THE ONLINE REFILL SYSTEM. Simply click HERE or on the Online Refills tile below, choose Home Delivery as your pharmacy and enter your prescription numbers.


If you are unsure whether you are already a Home Delivery customer, or if your information has changed since your last refill, DO NOT FILL OUT THIS FORM. Instead, call our Home Delivery Sevice toll-free at 1-855-849-8555.


Your personal information is confidential. Please see our Terms of Use and Privacy Policy.


Current states HomeTown ships to: Georgia, Massachusetts, Michigan, Pennsylvania

New states are being added frequently - give us a call at 1-855-849-8555 if your state is not listed.



Name:
Address:
City:
State:
Zip:
Phone:
Alternate Phone:
Email Address:
 
Cash or Insurance?
Insurance Provider:
Plan Name:
Member ID:
Group:
BIN:
PCN:
Primary Cardholder Name:
(If different than self)
Cardholder Birthdate:
eg. 1/1/2001
Cardholder Phone:
Relationship to Cardholder:
 
Physician Name:
Physician Phone:
 
Your SSN:
eg. 123-45-6789
Your Birthdate:
eg. 1/1/2001
Your Gender:
Your Allergies:
Other Allergies:
Other Health Concerns:
Prefer easy-open caps?:
 
Dependents:
  Name Relationship Gender Birthdate SSN Allergies
1
2
3
4
5
 
Dependent notes:
 
Method of Payment:
Terms of Agreement:
I certify that the information provided on this form is current and authorize the release of all information to the plan sponsor, administrator or underwriter; and I AUTHORIZE HOMETOWN PHARMACY TO UTILIZE THIS INFORMATION TO PROVIDE PRESCRIPTION SERVICES.
HIPAA Release:
Please review our HIPAA/Privacy policy and indicate your acceptance below.
 

Conditions and Privacy


All personal information submitted on this form will be held in strict confidence and is covered by our Privacy Policy. Please read it carefully before submitting.

 






How are we doing?


Take our survey online
or download and mail it in.

Find a
pharmacy
near you




click to search now >

Long-Term
Care

LARGE enough
to offer all the resources,
SMALL enough
to truly care
click to learn more >
      Copyright © HomeTown Pharmacy 2012         All Rights Reserved         HIPAA/Privacy        Intranet       Corporate Office 3001 W. M-20, New Era, MI 49446

Software error:

 at /var/webapps/hdsforms/www/index.cgi line 246.

For help, please send mail to the webmaster (webmaster@localhost), giving this error message and the time and date of the error.