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Get SCL Health Medical Group Mail Order Pharmacy Enrollment/Change Form

S, Good Samaritan Medical Center 200 Exempla Circle, Lafayette, CO 80026 Fax: 303-689-6126 Email: goodsamrx sclhs.net (Add secure to the subject line) Questions? Call 303-689-6121 or Toll Free 855-235-4301 Please destroy this form after submitting it to the pharmacy. * Required fields are indicated with a red asterisk below. PATIENT INFORMATION * Last Name: * First Name: * Birthday: * Sex: o Male o Female o Please no child-proof caps SHIP TO THIS ADDRESS o PLEASE CHECK HERE.

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