Community Healthcare Center of Central Wyoming Pharmacy
5000 Blackmore Road
Casper WY 82609
307B233-6066 or 800-500-9552
Fax number 307-233-6087
CHCCW Pharmacy is your employers contracted mail order pharmacy. The mail order program provides a 90 day supply of
maintenance medications. Costs for these prescriptions are usually at a much reduced rate. Please call if you have question
on costs or refer to your provider manual for co-pay information.
CHCCW strides to provide excellent service and timely delivery. You can expect your prescriptions to be processed and delivered
within 5-10 business days. If you are a new customer please fill out the basic information below. After completion please mail
the form with your prescriptions for 90 day supply to CHCCW PHARMACY 5000 Blackmore Road , Casper , Wyo. 82609.
Make sure you have your contact information included so that we may call or email you with any questions we have. We look
forward to serving you!
Patient Information Sheet
Patient=s Name:
DOB:
Address:
Home Phone:
Work Phone:
Insured=s Name:
Insured=s ID#:
Insured=s Employer:
Insured=s Group #:
Physicians Name:
Physician Phone Number:
Allergies:
What prescription medications are you currently taking?
What over the counter medications and herbal supplements do you take?
For your convenience, you may pay by credit card.
SSN:
Email Address
Please complete the following information.
Credit Card Visa_____ MasterCard ____ Discover____ Account Number _____________________ Exp Date_______ Sec Code_______
_____ I authorize the billing of this credit card for new and refill prescriptions at CHCCW Pharmacy for a period of one year from
the date of signature.
Cardholders= Signature:___________________________________________________
Date: __________________
______I authorize the use of Generic Substitutions when they are available.
______ I authorize the use of therapeutic interchange when authorized by my physician.
Patient Signature:(Parent if a minor)_________________________________________________ Date: __________________________
Prescriptions will be filled as written by the physician; please request a 90 day supply.
Please add additional family members on the back
Patient Name:
DOB:
Physician=s Name:
Allergies:
What prescription medications are you currently taking?
What over the counter or herbal medications do you take?
Relationship to insured
Physician=s Phone:
Please circle any of the following conditions diagnosed by your physician:
High Blood Pressure
Heart Disease
Diabetes
Asthma
Anemia
Headaches
Depression
Lung/Breathing Disorders
Disease of the Liver
Disease of the Bowel/Bladder
Kidney Problems
Stomach Ulcer/Pain
Anxiety
Thyroid Problems
Pregnancy
Skin Disorders
Osteoporosis
Arthritis
Parkinson=s
Other (i.e., constipation, etc.)
Patient Name:
DOB:
Physician=s Name:
Allergies:
What prescription medications are you currently taking?
What over the counter or herbal medications do you take?
Relationship to insured
Physician=s Phone:
Please circle any of the following conditions diagnosed by your physician:
High Blood Pressure
Heart Disease
Diabetes
Asthma
Anemia
Headaches
Depression
Lung/Breathing Disorders
Disease of the Liver
Disease of the Bowel/Bladder
Kidney Problems
Stomach Ulcer/Pain
Anxiety
Thyroid Problems
Pregnancy
Skin Disorders
Osteoporosis
Arthritis
Parkinson=s
Other (i.e., constipation, etc.)
Patient Name:
DOB:
Physician=s Name:
Allergies:
What prescription medications are you currently taking?
What over the counter or herbal medications do you take?
Relationship to insured
Physician=s Phone:
Please circle any of the following conditions diagnosed by your physician:
High Blood Pressure
Heart Disease
Diabetes
Asthma
Anemia
Headaches
Depression
Lung/Breathing Disorders
Disease of the Liver
Disease of the Bowel/Bladder
Kidney Problems
Stomach Ulcer/Pain
Anxiety
Thyroid Problems
Pregnancy
Skin Disorders
Osteoporosis
Arthritis
Parkinson=s
Other (i.e., constipation, etc.)