Forms


Find the form you need from the list below.


Prescription Delivery Enrollment Form   (Español)
This form should be used to enroll in mail order service, add dependents, or update your information.

Protected Health Information Authorization
Authorization for WellDyneRx to provide access to Members Protected Health Information (PHI) to another Individual

Mail Order Prescription History Request
This form should be used by the member or his/her Personal Representative to request printouts of the member’s prescription history.

Specialty Pharmacy Enrollment Form
This form should be used for new enrollment in our specialty pharmacy program.


Forms


Find the form you need from the list below.


Prescription Delivery Enrollment Form   (Español)
This form should be used to enroll in mail order service, add dependents, or update your information.

Protected Health Information Authorization
Authorization for WellDyneRx to provide access to Members Protected Health Information (PHI) to another Individual

Mail Order Prescription History Request
This form should be used by the member or his/her Personal Representative to request printouts of the member’s prescription history.

Specialty Pharmacy Enrollment Form
This form should be used for new enrollment in our specialty pharmacy program.



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