Locate and fill-out the form you need from the list below.
Prescription Delivery Enrollment Form (Español)This form should be used to enroll in mail order service, add dependents, or update your information.
Protected Health Information Authorization Authorization for WellDyneRx to provide access to Members Protected Health Information (PHI) to another Individual
Mail Order Prescription History Request This form should be used by the member or his/her Personal Representative to request printouts of the member’s prescription history.
The links above point to .pdf documents, which can be read with Adobe Reader.
We have recently redesigned our website to make ordering your prescriptions quicker and easier.
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Our records have as your email Address.
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