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Member Registration

Required Information

Tell us about yourself.
First Name:
Last Name:
Date of Birth:  (mm/dd/yyyy)
Gender:
Phone:  (999-999-9999)

Tell us about your Allergies.
Penicillin Sulfa Erythromycin Codeine Aspirin
To put additional allergies on file you can contact our toll-free help line at: 1-866-909-5170 (TTY Users should call 711).

Tell us about your member information.
Member ID: (Prescription ID number from your Insurance ID Card)
Relationship:

Provide your e-mail address and create a password.
In accordance with Health Insurance Portability and Accountability Act (HIPAA) guidelines, we protect your private healthcare information. To accomplish this, all members over the age of 18 are required to register using a unique email address. Once registered, each member may elect to grant or deny access to their healthcare information by the primary cardholder.
You will use this information to log in and access your information each time you return to the site.
Enter your e-mail address:
 (Example: yourscreenname@aol.com)
Confirm e-mail address:
 (Retype your e-mail address exactly as you did above)
Create a password:
 (Must be at least 6 characters. All passwords are cAsE-sEnSitiVe)
Confirm password:
 (Retype your password exactly as you did above)
Provide a password hint.
To help you remember the password you created, enter a short description here. If you forget your password, we will display this hint to help you remember. For your security, please do not enter your exact password, or any phrase easily identifiable by anyone else. Note that when you request your hint, it will be displayed to you online after you enter your user ID (e-mail address).
Enter a hint phrase:
 View example of a password hint
Provide a secret question.
For your security, choose one of the secret questions below and enter your answer. We will ask you for this information if you forget your password.
Secret question:
Secret answer:
By checking here, you are acknowledging the electronic delivery of the Notice of Privacy Practices.