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CLIENT information update form

You may also provide us with your updated information directly by one of the following:

 

  • speak with one of our Partner Specialists by phone at 443.290.6337, or

IDENTIFYING INFORMATION

WORK COMP DATA

On average, collectively among all work comp professionals at your business, how many NEW work comp patients / clients does your medical practice / law firm see in a week?

NEW OR ADDITIONAL WORK COMP PROFESSIONALS

New OR Additional Work Comp Professional #1

New OR Additional Work Comp Professional #2

New OR Additional Work Comp Professional #3

EZ SCRIPTS PHARMACY SUPPORT

I / We need to replenish our materials on the benefits of using EZ Scripts Pharmacy to give to patients / clients.
Our office needs additional rack card holders and rack cards, which give an overview for EZ Scripts Pharmacy, to put in every office / exam room.
Our new and/or additional work comp staff need a brief introduction on EZ Scripts Pharmacy to better understand its role and relationship with our medical practice / law firm.
Our office needs EZ Scripts Pharmacy materials in Spanish for patients / clients.

OTHER INFORMATION

Thank you for providing updated information for your EZ Scripts Pharmacy's Work Comp Partner Record. One of our Partner Specialists will call you soon should we have follow-up questions to be able to update your file.

 

We appreciate you being a valued referral source for injured workers needing fast, convenient, work comp medications delivered to their homes.

 

We look forward to our continued partnership with you.

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