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INJURED WORKER information update form

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

 

  1. Complete the form below.

  2. Speak with one of our Injured Worker Care Specialists by phone at 443.290.6337.

  3. Provide details via email at enroll@ezrxmeds.com.

INJURED WORKER'S IDENTIFYING INFORMATION

INJURED WORKER'S NEW CONTACT INFORMATION

INJURED WORKER'S NEW MAILING ADDRESS

INJURED WORKER'S NEW OR ADDITIONAL HEALTH CARE SPECIALISTS

Injured worker has additional work comp specialists for their injury:

INJURED WORKER'S WORK COMP ATTORNEY INFORMATION

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

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'S PREFERRED LANGUAGE

OTHER INFORMATION

Thank you for providing updated information for your patient record!

One of our Patient Care Specialists will call you should we have follow-up questions to update your file.

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