EnvisionMail Prescription Program Enrollment Form

To submit this form, you have several options. You can mail your completed form and original prescriptions to EnvisionMail at 7835 Freedom Ave NW, North Canton OH 44720. Alternatively, you can enroll online at envisionpharmacies.com or call 1-866-909-5170 or TTY 711 during business hours for assistance with your submission.

The enrollment for the EnvisionMail prescription program operates throughout the year, with easy access to services, but members should be mindful of their specific medication needs and renewals due prior to medication running out. Keep track of prescription refills regularly to avoid delays in receiving essential medications.

The purpose of this enrollment form is to facilitate easy access to the EnvisionMail prescription delivery service. By filling out this form, members can securely enroll in the program, ensuring they receive their medications conveniently at home. It also provides crucial details for both the pharmacy and the members to manage prescriptions effectively.

• 1. Last Name: Member's last name for identification.
• 2. First Name: Member's first name for identification.
• 3. Middle Initial: Optional middle initial of the member.
• 4. Address: Primary address for medication delivery.
• 5. Apt. #: Apartment number if applicable.
• 6. City: City of residence.
• 7. State: State of residence.
• 8. Zip Code: Postal code for address verification.
• 9. Phone Number: Member's telephone number for contact.
• 10. Group Number: Insurance or membership group number.
• 11. Member Identification Number: Unique identifier for member in the system.
• 12. Date of Birth: Member's date of birth for age verification.
• 13. Sex: Gender of the member.
• 14. Email: Email address for communication.
• 15. Drug Allergies: List of known allergies of the member.
• 16. Payment Method: Preferred method of payment for medications.
• 17. Signature: Member's signature authorizing the form.

If you fail to submit this form correctly, your enrollment in the EnvisionMail program may be delayed. This can lead to interruptions in receiving your medications on time. It is crucial to ensure all required fields are filled out accurately and completely before submission.

• Delay in Medication Delivery: Incomplete submissions can lead to delays in your medication reaching you.
• Inaccurate Information: Mistakes in your information may result in issues with orders.
• Loss of Coverage: Failure to complete the form may risk your eligibility for the program.

• 1. New Enrollment: To sign up for EnvisionMail services as a new member.
• 2. Updating Information: To update personal or payment information for existing members.
• 3. Access to Home Delivery: Used to ensure continuous medication delivery to your home.