Patient Intake Form for PriceMDs Treatment Cost Containment ProgramReferring Vendor *Vendor Type *SelectCaptiveConsultantPre-Certification/Prior AuthorizationCare ManagementTPAStop LossEmployer Group *Member InformationMember First Name *Member Last Name *Date of BirthPhone NumberEmail Address*Must provide a phone number or email, preferably bothMember relationship to insured?SelectSelfSpousePartnerDependentMember's preferred method of communication?PhoneEmailTextOtherIs there a preferred time to be reached?AMPMSelect a time.Medication Name *Enter member medication name.Strength *(E.g. 40mg, 3ml etc.)Frequency of Use *(E.g. Twice a day, once a week etc.)Has member started this medication? *YesNo*PriceMDs cannot provide the first dose of any new medication.Member has been told that a PriceMDs Nurse Navigator will contact them about PriceMDs’ International sourcing program? *YesNoDoes member have a passport?SelectHas a passportApplied for passportNeeds to apply for passportUpload a copy of passport, medical records, or any relevant documents.Drag and Drop (or) Choose Files*Passport book, card, or expired is acceptableSubmitPlease do not fill in this field.
