Patient Referral

  1. Please complete the form below if you are a patient and require reimbursement coordination assistance for your medication(s) and pharmacy services.
  2. Please complete the form below if you are registering your patient for reimbursement coordination assistance and pharmacy services and are a Healthcare Professional.

Patients will be contacted within 24 hours by a member of our Patient Support Services Team.

PATIENT INFORMATION
CLINICAL INFORMATION

PRESCRIBING PHYSICIAN INFORMATION
PATIENT CONSENT
  • I acknowledge that I am the patient/caregiver referenced above and that I am providing consent to share the information contained on this registration form with Rx Infinity.
  • I acknowledge that I have obtained verbal permission from the above patient/caregiver to share the information contained on this registration form with Rx Infinity.