Vivid Onboarding Mail Order Welcome Packet

Time-Stamp

MonthDayYear
Date
Hour Minutes
Hy-Vee Mail Order
Transfer prescriptions to Hy-Vee Vivid Home Delivery pharmacy
Patient Information
First Name*
Last Name*
Date of Birth*

MonthDayYear
Mobile Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Information
Vivid Clear Rx BIN
Vivid Clear Rx PCN
Vivid Clear Rx ID
Vivid Clear Rx Group
Prescription(s) to be transferred
Which pharmacy currently has your prescription(s)*
Pharmacy Phone Number*
Phone for pharmacy that currently has your prescription
Which prescriptions are we transferring?*

I want to transfer all my prescriptions to Hy-Vee Vivid Home Delivery pharmacyI want to transfer just the prescriptions I list to Hy-Vee Vivid Home Delivery pharmacy

Mail Order Welcome Packet
This welcome packet contains important notifications, forms about your rights and responsibilities, and information about Hy-Vee Mail Order's services.

Please complete the Patient Health Information and Patient Checklist. Then, please review and agree to to the Patient Rights & Responsibilities, Notice of Privacy Practices, and Frequently Asked Questions and sign below.

You can review the entire welcome packet by clicking "Preview Document" below. If you elect to provide your email address, you will also receive a copy of your signed agreement.
Patient Health Information
Health Conditions. Check all that apply*

NoneArthritisAsthmaBlood DisorderCancerCOPDCongestive Heart FailureCystic FibrosisDiabetesDepressionEpilepsyGlaucomaHeart ConditionHepatitisHigh CholesterolHIV/AIDSHypertensionMultiple SclerosisOrgan TransplantSeizuresSinusitisUlcerOther(s)
You have selected None and other Health Conditions. Please review your selections.
Health Conditions validation calculation
Drug Allergies. Check all that apply*

NoneAspirinCodeineErythromycinSulfaPenicillinOther(s)
You have selected None and other Drug Allergies. Please review your selections.
Drug Allergies validation calculation
Please list all prescriptions and any over-the-counter medication (i.e. aspirin, vitamins, antacids, dietary and herbal supplements) that you are taking. This information enables us to provide better assistance in helping you manage your medication therapy.

Current Medications

	Medication
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Patient Checklist
This form is to acknowledge that I have received the New Patient Welcome Packet. Please complete this form and submit within 10 days.
Are you the patient or an authorized representative?*

PatientAuthorized Representative
Authorized Representative's Relation to Patient:
Please read the following statements and check the appropriate box (Yes or No) for each item.
Release of information. I hereby authorize release to Hy-Vee Mail Order any and all of my medical records pertaining to my medical history, services rendered, or treatments received from my physician(s) or hospital. In order to process insurance claims, I also hereby authorize Hy-Vee Mail Order to furnish to my insurance carrier(s) any medical history, services rendered, or treatment needed. For more complete information, please review the Notice of Privacy Practices.*

YesNo
Assignment of benefits. I authorize direct payment of insurance benefits by my insurance company to Hy-Vee Mail Order. In the event that my insurance carrier does not accept "assignment of benefits," I understand the payments may be sent directly to me and that I am obligated to endorse and directly send such payments to Hy-Vee Mail Order for payment of my bill. It is my responsibility to notify Hy-Vee Mail Order of any changes to my insurance information. I understand that I am responsible to Hy-Vee Mail Order for all charges not covered by my insurance. I recognize that in the event that my insurance company, employer, or any other third party payer refuses to pay the purchase price(s) of the items, or delays payment beyond 90 days of my receipt of items, or in the event that I have no insurance coverage or third party payer, that I will be responsible for said payments and will make prompt reimbursement within 30 days of notification by Hy-Vee Mail Order for invoiced charges.*

YesNo

MEDICATION DISPOSAL
Dispose Safely. Prevent Abuse.

Dispose of unused or expired medications the safe way, by bringing them to an approved collection site.

Drugs that are thrown in the trash can be retrieved by others and sold, while flushing medications can potentially contaminate the water supply. By safely disposing, you will help prevent poisoning, misuse, and overdose your community.

Safe disposal is more convenient than you think. There are thousands of permanent drug disposal boxes throughout the country. To find a location near you, visit nabp.pharmacy/drug-disposal.

AWARxE Prescription Drug Safety ― A program of The National Association of Boards of Pharmacy

Disposing of medication at home

If a drug disposal site or mail-back program is not available in your area, it is best to follow Food and Drug Administration (FDA) guidelines for the safe disposal of unused or unwanted medications at home; including when to flush medication and patches.

https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know

Disposing properly, at a glance.

1.     Check the label on your medication and follow any instructions for safe disposal provided.

2.     A small number of medications need to be flushed down the toilet if a disposal box is not immediately available. These drugs include fentanyl, hydrocodone, and methadone, among others. The list of drugs that should be flushed when take-back options are unavailable is available on the FDA website.

3.     If there are no take-back programs available in your area and there are no specific instructions, such as flushing, take your medication out of the container and mix them with an undesirable substance such as dirt, used coffee grounds, or cat litter. Next, seal the mixture in a sealable bag, can, or container and place the container in the garbage.

If disposing of sharps, place the sharps immediately in a sharps disposal container, which are often available through pharmacies, medical supply companies, etc. If a disposal site is not available, you may use heavy-duty household container, such as a laundry detergent container to dispose of the sharps.

DISPOSAL OF A SHARPS CONTAINER
How to get rid of a sharps container. Safe disposal of needles and other sharps used at home, at work, or while traveling.

There are several ways to get rid of a sharps disposal container. Check with your local trash removal services or health department (listed in the city or county government (blue) pages in your phone book) or search the Internet for safe sharps disposal programs available in your area.

Some examples of safe sharps disposal methods are briefly described below:

1. Drop Box or Supervised Collection Sites – You may be able to drop off your sharps disposal containers at collections sites, such as doctors’ offices, hospitals, pharmacies, health departments, medical waste facilities, and police or fire stations. Services may be free or have a nominal fee.

2. Household Hazardous Waste Collection Sites – You may be able to drop off your sharps disposal containers at local public household hazardous waste collection sites. These are sites that also commonly accept hazardous materials such as household cleaners, paints, and motor oil.

3. Mail-Back Programs – You may be able to mail certain FDA-cleared sharps disposal containers to a collection site for proper disposal. This service usually requires a fee. Fees vary, depending on the size of the container. Follow the manufacturer’s instructions included with the disposal container, as these programs may have specific requirements for mail-back.

4. Residential Special Waste Pickup Services – Your community may provide pick-up services using a sharps disposal container acceptable to the pick up company, either provided to you by the pickup services company or one that you already own, depending on the company guidelines for pick up. The container is placed outside the home for collection by trained special waste handlers. Some programs require customers to call for

Read and Acknowledge Header
You are required to read the full text before acknowledging the following:
Name of Signer*
Signature*

Powered by Jotform SignClear
If you elect to receive a copy of your signed document via email by providing your email address below, you will receive two separate emails. One will contain a password protected PDF of your signed document. The other will contain the password to access the document.
Please enter your email to receive a copy of the signed document

Confirmation EmailVerify Email
Hy-Vee Mail Order Hours of Operation:

Monday - Friday 8am to 4pm

Contact Us:

866.794.9833 | MailOrder@hy-vee.com
You have selected None and other Health Conditions. Please review your selections before proceeding.
You have selected None and other Drug Allergies. Please review your selections before proceeding.
Should be Empty:

	Medication	Rx number (optional)
1
2
3
4
5
6
7
8
9
10

Transfer prescriptions to Hy-Vee Vivid Home Delivery pharmacy

Patient Information

Insurance Information

Prescription(s) to be transferred

Mail Order Welcome Packet

Patient Health Information

Patient Checklist