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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

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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

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New OR Additional Work Comp Professional #2

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New OR Additional Work Comp Professional #3

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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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