Enrollment

Please fill out the enrollment form or call our toll-free number.

  ENROLLMENT FORM
         
  The following information is needed to complete your file for Workers Comp Rx.
Please fill out this form in it's entirety.
  All fields marked with * are required.
  The phone numbers should be entered in the following format: XXX-XXX-XXXX xXX. The extension is not required.
         
  Name     Gender *  
  Last Name *
  First Name *
  Middle Name    
         
         
  Address      
  Street * State *
  Apt# Zip Code *
  City *    
         
         
  Phone Number    
  Home Work
         
         
  Date of Birth * Social Security Number *
         
         
  Date of Injury * Body Part Injured *
         
         
  Workers Compensation
Insurance Carrier 		   
  Name * Phone Number
         
         
  Claim Number *    
         
         
  Employer      
  Name * Phone Number
  City * State *
         
         
  The following information is necessary to file claims to your insurance company.
         
         
  Referred by      
  Attorney or Physician Name * Phone Number
         
         
 

By submitting this form, I certify that the information on this form is accurate and complete.

I authorize payment of medical benefits to Workers Comp Rx. I hereby authorize any doctor, hospital or other provider who participated in my care and treatment to release to Workers Comp Rx all medical or other information requested for processing of my claim(s).
 


Workers Comp Rx
a UnitedHealth Group Company
1800 Byberry Road - Suite 1202; Huntingdon Valley, PA 19006
 Email us at Workers Comp Rx ; (888) 2COMPRX or (888) 226-6779
©1999-2008 Prescription Services of America. All rights reserved.