Mail In Form ONLY! Mailing Address
MEMBER INFORMATION ( please print)
NAME:
PHONE: ( )
   
Area Code
 
ADDRESS:
CITY: STATE: ZIP: M F
SOCIAL SECURITY #
DATE OF BIRTH - Month Day Year
SPOUSE INFORMATION
NAME: DATE OF BIRTH - Month Day Year
DEPENDENT INFORMATION
NAME: DATE OF BIRTH - Month Day Year
NAME: DATE OF BIRTH - Month Day Year
NAME: DATE OF BIRTH - Month Day Year
I hereby apply for membership enrollment in Liberty Benefits Prescription Program. I understand that acceptance of this application of membership enrollment is guaranteed, that my enrollment will become effective once my membership card is received. I also understand that by participating in this program external factors may force a change in monthly fee, benefits and /or preferred drug list at any time. I will be entitled to negotiated and funded discounts on eligible prescription drugs purchased from any participating pharmacy.
Upon enrollment you will receive a Membership Kit including a complete listing of preferred drugs, a personalized plastic identification card and answers to frequently asked questions.
As a member of Liberty Benefits Prescription Program we understand that your trust in us is one of our most important assets. In order to preserve that trust, we want you to understand our information practices and your rights to ask us not to share certain information about you. As a member of this plan we want you to know the following: "THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY."
Liberty Benefits Prescription Program will without your consent of authorization submit online pharmacy claim data to manufacturers, with NO member identification, for the payment of the rebates. Online Claims data will also be provided to employers and pharmacies regarding invoicing and payments in the standard NCPDP claims billing format.
If you have signed up for the email online reminders regarding refills of your current medications, emails will be sent to you directly at the email address you list on your on link enrollment application.
If you wish to revoke the right for us to use your personal health information (PHI), you must do so in writing to Liberty Benefits, 911 1st Ave. NW, Ardmore, Oklahoma 73401. Your request will be processed within 60 days upon receipt. Revoking the right for us to use your personal health information may also terminate your benefit.
Enrollee Signature: Date:
Signature authorizes release of information and enrollment into the Program