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Choose Fisher's SPS as your specialized pharmacy for your specialized medication needs today. Complete the information below and forward onto us electronically. Fisher's SPS will follow-up with your physician to obtain your prescriptions and follow-up with your insurance company to verify coverage for each of your medications. As well as offer medication counseling, insurance coverage verifications and delivery confirmation to you.

Our commitment to your right of privacy
 
Fields in red are required.

Your Information

Your Shipping Information

First Name:

 Street:
Apartment #:

Middle Initial:

Last Name:

 City:

Date of Birth:

 / / State:

Diagnosis:

 Zip:

Telephone Number (Day):

 Telephone Number (Evening):

  

 E-Mail Address:

  
If you're not there when we call, may we leave a message that Fisher's SPS called?: 
 

Insurance Information:

  Physician Information:
Insurance Company: Physician Name:
Name of Insured: Specialty:
City: Phone:
State:  
Zip:
Employer:    
ID #:
Group #:
 

 

DISCLAIMER 

By electronically transmitting this information to Fisher's SPS, I authorize Fisher's SPS to:

1.  Promptly verify my prescription coverage under the insurance plan(s) identified above.
2.  Call me to confirm my prescription coverage and delivery date for my medications.
3.  Obtain prescription information from the physician identified above.
4.  I understand that by choosing to enroll in the Fisher's SPS program, I will receive some or all the following services from Fisher's SPS:  periodic phone calls and/or letters for the purpose of reminding me to refill my medications as prescribed by my physician, assistance with reimbursement issues, and educational phone calls and mailings relating to my condition.
5.  I understand that I will be responsible for the cost of my medications if Fisher's SPS does not receive payment from my insurance company or payer.

By electronically transmitting this enrollment to Fisher's SPS, I certify that I have read and accepted the terms of this enrollment.  I also certify that I am the patient or that I am duly authorized by the patient as the patient's agent to accept and transmit this patient enrollment on the patient's behalf.