PursueCareRx Pharmacy | Addiction Recovery Medication

Enrollment Form
Prescription Refill
Prescription Transfer
Patient Information Update

✕

Prescription Refill Form

Patient Information:

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Medication Information:

Medications requested for reorder(Required)

Medication Name

Strength

Quantity

Click the + button to add more rows.

Do you have any questions for the Pharmacist?(Required)

Yes

No

Questions for the pharmacist(Required)

Order request must be received by 12 Noon EST for same-day shipping.

Shipping Information:

Shipping method(Required)

Pick-Up at Pharmacy

UPS - Free (initial fill only)

UPS Partial Order Fill - $20

UPS Overnight Shipping - $45

UPS Saturday Delivery - $65

Optional Notes/Requests/Delivery Instructions

Order request must be received by 12 Noon EST for same-day shipping.

Name(Required)

First Last

Shipping Address (This is the address we will ship your order to)(Required)

Street Address City State ZIP Code

Biling Information:

Consent(Required)

I authorize a PursueCareRx representative to contact me by telephone to verify any order or payment information.(Required)

Please choose one of the billing options below:(Required)

No Prescription Insurance (pay via credit card)

Insurance with Copay (run insurance first with balance/copay on credit card)

Insurance with No Copay (run through insurance only)

Split Payment checkbox

I would like to split the payment between 2 credit cards.

Cardholder Name(Required)

First Last

Phone Number(Required)

Relationship to patient(Required)

If other:(Required)

Billing name and address same as shipping

Billing name and address same as shipping.

Billing Address (This is the address associated with your payment card)(Required)

Street Address City State ZIP Code

Card Number(Required)

This field is hidden when viewing the form

Exp. Date

Exp. Date(Required)

CVV Number

Amount to charge on this card:(Required)

Card #2

Cardholder Name(Required)

First Last

Phone Number(Required)

Relationship to patient(Required)

Billing Address (This is the address associated with your payment card)(Required)

Street Address City State ZIP Code

Card Number(Required)

Exp. Date(Required)

CVV Number

Amount to charge on this card:(Required)

Insurance Information

Insurance information on file

My insurance information is on file already

Insurance company name(Required)

Policy holder's name(Required)

First Last

ID Number(Required)

BIN Number(Required)

PCN Number(Required)

Rx group Number(Required)

Optionally upload images of the front and back of your insurance card.

Drop files here or

Max. file size: 5 MB, Max. files: 2.

CAPTCHA

Questions?

Call the pharmacy on our toll-free number: 1-800-541-2030, or email us at info@pursuecarerx.com to send us a message.

© 2026 PursueCareRx. All Rights Reserved.
Terms of Use | Privacy Policy
PursueCareRx is not an emergency service. If this is an emergency seek care immediately by dialing 9-1-1. If you are experiencing distress or are at risk of suicide or harm confidential support is available to you by contacting the Suicide and Crisis Lifeline by dialing 9-8-8.