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443-290-6337

EZ Scripts Pharmacy is closed for the holiday weekend.

Data Update Form

Provide us with any changes to your information by one of the following:

Complete the form below.
Speak with Pharmacy Staff by phone at 443.290.6337.
Provide details via email at [email protected].

INJURED WORKER'S IDENTIFYING INFORMATION

First & Last Name*

Date of Birth*

INJURED WORKER'S NEW CONTACT INFORMATION

NEW Email Address

NEW Phone #

SMS consent

SMS Approval: By checking this box, you are giving consent to receive information/marketing/service information related to your request by text message/SMS from the Brand EZ Scripts. The frequency of messages may vary. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. Text help for help 443.290.6337 & reply 'stop' to unsubscribe.
View full Privacy Policy here.

INJURED WORKER'S NEW MAILING ADDRESS

Street Address

Street Address 2

City

Region/State/Province

Postal / Zip code

INJURED WORKER'S NEW OR ADDITIONAL HEALTH CARE SPECIALISTS

Health Care Specialist's First & Last Name

Health Care Specialist's Phone #

Health Care Specialist's Phone #

Practice Location of Specialist

Injured worker has additional work comp specialists for their injury:

yes/no

yes no

INJURED WORKER'S NEW OR ADDITIONAL HEALTH CARE SPECIALISTS

Attorney's First & Last Name

Attorney's Phone #

Location of Law Firm

Injured worker is working with an attorney for the first time

Injured worker is working with an attorney for the first time Injured worker has switched attorneys Injured worker was working with any attorney but is no longer

Injured worker has more work comp, case manager, and/or paralegal information to provide:

Injured worker has more work comp, case manager, and/or paralegal information to provide:

Yes No

INJURED WORKER'S OTHER PHARMACY INFORMATION

Is the injured worker currently filling all or some of their work comp prescriptions at another pharmacy?

Injured worker has more work comp, case manager, and/or paralegal information to provide:

Yes No

If yes, please provide the name and location of the pharmacy:

INJURED WORKER'S PREFERRED LANGUAGE

What is the injured worker's preferred language?

OTHER INFORMATION

Please provide any other updates below that are relevant to the injured worker's record.

What a work comp pharmacy should be

NPI: 1356621619
NCPDP: 3679860

LegitScript Certified

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Monday – Friday: 9:00 am - 5:30 pm ET
Saturday: 10:00 am - 2:00 pm ET
Sunday: closed

24340 Sperry Dr, 2nd Floor
Westlake, OH 44145-1565
P: 443.290.6337
F: 855.879.4949
[email protected]

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