ReconRx Online Enrollment

Let's get started!

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

NCPDP
Pharmacy Name
Pharmacy Legal Name
Federal Tax Class
Medicaid Number
Software Vendor
Drug Wholesaler
End of your current Fiscal Year
e.g. MM/DD/YYYY
NPI
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
City
State
Zip
County or Parish

Mailing Address

Same as physical

Address Line 1
Address Line 2
City
State
Zip
County or Parish

Owner Contact Information

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

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 Email
Primary Contact Phone
e.g. (555) 555-5555
Primary Contact Cell
e.g. (555) 555-5555
Primary Contact Fax
e.g. (555) 555-5555

Signature Name for ReconRx Agreement

Same as Owner Contact Information

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

Authorized Signature Name (Full)
Authorized Signature Title
Authorized Signature Email
Authorized Signature Phone
e.g. (555) 555-5555
Authorized Signature Fax
e.g. (555) 555-5555

Authorized Name for EFT Signature

Same as Owner Contact Information

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

Authorized Name for EFT Signature (Full)
Authorized Name for EFT Title
Authorized Name for EFT Email
Authorized Name for EFT Phone
e.g. (555) 555-5555
Authorized Name for EFT Fax
e.g. (555) 555-5555

Authorized Name for 835 Signature

Same as Owner Contact Information

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

Authorized Name for 835 Signature (Full)
Authorized Name for 835 Title
Authorized Name for 835 Email
Authorized Name for 835 Phone
e.g. (555) 555-5555
Authorized Name for 835 Fax
e.g. (555) 555-5555

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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