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Home Delivery - Enrollment

Please read the following directions thoroughly before submitting your Home Delivery form online.Your personal information is confidential. Please see our Terms of Use and Privacy Policy. Alternatively, you may download this form, print and mail it in if you do not wish to submit your information through the online enrollment form.

New Home Delivery Service Customers

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.

Existing Home Delivery Service Customers

If you are already a Home Delivery customer, you do not need to fill out this form to use the online refill system. Simply use the standard Online Refills form. Choose Home Delivery as your pharmacy and enter your prescription numbers.

Online Refills

Unsure if You're a Customer?

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.

Current states HomeTown ships to for Home Delivery Services are Georgia, Massachusetts, Michigan and Pennsylvania. New states are being added frequently - give us a call at 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.