No Money Left Behind

User ID

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Please complete the following three sections. Once completed and submitted, you will be given pre-populated documents to print, sign, and return to ReconRx.

Pharmacy Information

Pharmacy Name
Pharmacy Legal Name
Federal Tax Class
Medicaid Number
Software Vendor
Drug Wholesaler
End of your current Fiscal Year
Federal Tax ID
Switch Company (Primary)
Switch Company (Secondary)
Current PSAO

Phone (Pharmacy)
e.g. (555) 555-5555
Fax (Pharmacy)
e.g. (555) 555-5555
Email (Pharmacy)
Communication Preference

Pharmacy Address

Physical Address

Address Line 1
Address Line 2
County or Parish

Mailing Address

Same as physical

Address Line 1
Address Line 2
County or Parish

Owner Contact Information

Owner Name (Full)
Owner Contact Phone
e.g. (555) 555-5555
Owner Contact Cell
e.g. (555) 555-5555
Owner Contact Email

Primary Contact Information

Same as Owner Contact Information

The Primary ReconRx Contact will have access to the pharmacy's member's section and will receive fax, email and phone communications regarding missing and recovered payments.>

Primary Contact Name (Full)
Primary Contact Title
Primary Contact Phone
e.g. (555) 555-5555
Primary Contact Cell
e.g. (555) 555-5555
Primary Contact Email

Authorized Contact Information

Same as Owner Contact Information

Contract documents will be pre-populated with the name and title entered below for Authorized Signature.

Authorized Contact Name (Full)
Authorized Contact Title

Additional Information

How did you hear about us?
Promo Code*

* If you received a promo code please enter it here. It will be reviewed by our staff on completion of the enrollment.

Clicking "Submit and Download Contracts" will generate your agreement packet, this could take up to 30 seconds so please be patient waiting for the next page to load.

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