Agelity NETWORK Mail Order Service

                  Prescription Mail Order Enrollment Form
              Patient Cardholder Information

Group Name: SEBA Healthmart America     Group Number: _______________    

Member ID: ______________________ - __01__
(as presented on card)
Patient's Name: _____________________ ____ __________________
(first) (MI) (Last)
Address: ___________________________________________
(street)
________________ ________________ ________
(city) (state) (zip)
Phone: _______________________________
Gender: ❍ Male ❍ Female
Date of Birth: ________ - _______ -_________
                         (month)          (day)          (year)

Allergies: ❍ None ❍ Aspirin ❍ Codeine ❍ Erythromycin ❍ Sulfa ❍ Tetracycline
❍ Penicillin ❍ Other: _________________________________________________________
Health Conditions: ❍ None ❍ Angina ❍ Asthma ❍ Congestive heart failure
❍ High blood pressure ❍ Kidney disorder ❍ Liver disorder
Other: _________________________________________________________
Payment Information
Please indicate a payment method:
❍ Check Check number: ___________________________
❍ Credit card ❍ Visa ❍ MasterCard ❍ Discover
Credit Card Number: _______________________________ Expiration Date: _____ - _____
                                                                                                                                         (month) (year)
Prescription Information
Please indicate if you are: ❍ Filling a New Prescription ❍ Refilling a Prescription ❍ Transferring a Prescription
If you are filling a new prescription, please include your doctor’s original prescription form.
If you are transferring prescription or refilling prescriptions, please list the 10-digit prescription numbers below.
Prescription #: ______________________Prescription #:______________________Prescription #:___________________

Physician's Name ________________________ Phone: _______________________
If you are transferring a prescription, please provide:
Pharmacy Name __________________________ Phone: _______________________
Additional mail order forms will be sent with your order.
For your first mail order prescription, please complete the information above and mail this
form along with your prescription to:
Agelity Mail Order Service
4230 L Street
Omaha, Nebraska 68107
Optionally, you may fax your order to us at 404-342-4425.