No Money Left Behind
Please complete the following three sections. Once completed and submitted, you will be given pre-populated documents to print, sign, and return to ReconRx.
Same as physical
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.
Contract documents will be pre-populated with the name and title entered below for Authorized Signature.
* 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.
Phone: (888) 255-6526
If at any time you need assistance completing this enrollment, please call or send us an email at the contacts listed above.
Program Details |