Za Post PO Box 4975 Rivonia 2128 Please attach your prescription to this application without a valid script we cannot dispense your medication. Authorization of chronic medication by your Medical Scheme remains your responsibility Optipharm will be unable to dispense your medication unless it is correctly authorized. DISCLAIMER Prescription supplied without a current valid prescription. Optipharm will notify you when a new prescription is required but it remains your responsibility to provide a valid prescription s to ensure that there is no interruption in your medicine delivery service. Application form for enrolling for chronic medicine delivery How to complete this form Please complete with black ink use one number per block and print clearly. To avoid administrative delays please ensure this application is completed in full. A. Main Member and Medical Scheme details Surname First name s ID Number Gender M F Medical Scheme Membership number Scheme Option Telephone H W Cell Email B.....
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How to fill out the Optipharm Chronic Form online
Completing the Optipharm Chronic Form online is a straightforward process that facilitates chronic medicine delivery. This guide is designed to provide clear, step-by-step instructions to help you fill out the form accurately and efficiently.
Follow the steps to complete your Optipharm Chronic Form.
- Click ‘Get Form’ button to access the Optipharm Chronic Form and open it in the online editor.
- In section A, enter the main member's details, including surname, first name(s), ID number, gender, medical scheme, membership number, scheme option, telephone numbers, and email. Ensure you use black ink and print clearly.
- Proceed to section B to input the patient's information. Include the patient's surname, first name(s), ID number, dependent number, gender, and contact details if they differ from the main member.
- Fill out section C with the preferred delivery address by selecting from options such as home, work, or doctor’s rooms. Provide the complete address, including unit/building number, street address, town, province, and postal code.
- After completing all sections, ensure that you attach a valid prescription to your application. Without a valid prescription, Optipharm cannot dispense medication.
- Once you have filled out the form and attached required documents, save your changes, download, print, or share the form as needed. Ensure all details are accurate before submission.
Complete your Optipharm Chronic Form online today to ensure a smooth chronic medicine delivery process.
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