New England Mail
Order Pharmacy

ph: 888.778.8667 • email: support@nemoprx.com
Contact Us

New Patient Information Form


For New Patients Only!

Please note: You may only use our services if your employer or affiliated organization has a contractual arrangement with us.

If your affiliation is not listed below please call us.

Account Information

Please enter the following information to create your NEMOP account.
Use this form only for new accounts.

(*) signifies a required field.

Enter your full name - first, middle initial & last.
Employee Full Name(*)
Please type your first and last name.

DOB(*)
Please enter a date

Gender(*)
Invalid Input

Allergies
Invalid Input

(Leave blank if none)

Current Medications

Please list any over the counter (OTC) medications or vitamins you currently take. Do not include prescriptions filled with us.

Important: Listing your medications here does not transfer them to us from your current pharmacy. If you have medications you'd like to transfer to NEMOP please complete the rest of this form then login to your account and, under the MY ACCOUNT menu, choose TRANSFER MY PRESCRIPTIONS.

Current Medications
Please list any current medications

Current Medical Conditions

Please list any current medical conditions that will help our pharmacist understand your needs.
Current Medical Conditions
Please list any current medical conditions

Create a user name for your online account. User names may be up to 24 characters and may consist of letters and numbers. The email address you enter will be used by us to communicate with you and provide automated shipment notifications when your prescriptions are mailed.
User Name(*)
Please create a user name.

Email(*)
Enter a valid email address.

Verify Email(*)
Enter a valid email address.

Please choose a password. It must be at least 6 and no more than 24 characters. Letters, numbers and !@#$%^&() characters are allowed.
Password(*)
Enter a password

Verify Password(*)
Enter a password

Employer/Affiliation Information

Select your employer or affiliated organization. If your employer or organization is not listed below please call us to discuss your options.
Organization(*)
Please select your employer

Enter your employee/organization insurance identification number.
Insurance ID#(*)
Please enter your Insurance ID number

 

Mailing/Billing Address

Please enter the address you use for correspondence and billing.
Billing Name(*)
Enter a name

PO Box/Street(*)
Enter a PO Box or Street Address

City/Town(*)
Enter a City or Town

State(*)

ZIP(*)
Please enter your ZIP code

Home Phone(*)
Enter a phone number (123-456-7890)

Work Phone
Enter a phone number

Cell Phone
Enter a phone number

Spouse/Domestic Partner

Enter full name - first, middle initial & last.
Full Name
Please type your first and last name.

DOB
Invalid Input

Gender
Invalid Input

Allergies
Invalid Input

(Leave blank if none)

Current Medications

Please list any medications - prescription or over the counter (OTC) - currently taken. You do not need to include prescriptions filled with us.
Current Medications
Please list any current medications

Current Medical Conditions

Please list any current medical conditions that will help our pharmacist understand your needs.
Current Medical Conditions
Please list any current medical conditions

Email
Enter a valid email address.

(If different from account holder)

Cell Phone
Enter a phone number

Shipping/Physical Address

(If different than mailing/billing address.)

Street
Enter a PO Box or Street Address

City/Town
Enter a City or Town

State

ZIP
Please enter your ZIP code

 

Drug Information

Enter your initials below if you do NOT want Child Resistant Containers.
Enter Your Initials
Please enter initials only.

Yes, I want to receive automatic shipping notification and prescription refill reminders. (Although we do not currently offer refill reminders we ask you provide this information since we anticipate this will be a service our software will enable in the near future. In the meantime we encourage you to use our Autofill Service.)
How should we remind you?

If Text Msg is selected, who is your cellphone provider?
Text Msg Carrier
Please select your cellular carrier.

New Prescriptions

You must mail your initial prescription(s) from your physician for each medication you are ordering.
(Your physician may also contact us directly.)

Vermont state law requires us to receive and fill prescriptions for narcotic and stimulant medications within 30 days from the date written.

Mail your prescriptions to:
NEMOP
111 Maple St.
Middlebury, VT 05753.

Refilling a Prescription

There are four (4) easy ways to get your NEMOP prescriptions refilled. If the prescription has already been filled at least once by us, you may enter a refill request online, email a request, fax a request, or call toll-free 1-800-778-8667 (local 802-388-1684).

Please Note: You may request your refills up to 3 weeks before running out!

Transferring a Prescription

If you would like a prescription refilled that you have on file at another pharmacy, please complete a Prescription Transfer Request available online under the My Account menu choice after you have logged in to the site.
(You may also download, print and mail the Transfer Request Form available under the Services menu above.

Automated Refills

Once your account has been created you may participate in our Autofill Program where your prescriptions will be filled automatically when due, prior to expiration.

If you wish to participate, select Autofill My Prescriptions under the My Account menu once you login to the site. (You will be responsible for all prescriptions shipped to you via NEMOP’s Autofill program and understand that NEMOP will not accept any returned medications for credit.)

 

HIPAA Policy Statement

Our company is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the services we provide to you.

This Notice tells you about the ways in which New England Mail Order Pharmacy (referred to as “we”) may collect, use, and disclose your protected health information and your rights concerning your protected health information. “Protected health information” is information about you that can reasonably be used to serve you and that relates to you, or the payment for that care.

We are required by law to maintain the confidentiality of health information that identifies you; and to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards. If you have questions about this notice, please contact our Privacy Officer for further information.

The terms of this notice apply to all records containing your health information that are created or retained by our organization. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records we have created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our office in a prominent location, and you may request a copy of our most current notice by calling us.

 

HIPAA Policy Statement - (cont.)

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI)

We may use and disclose your PHI for different purposes. The examples below are provided to illustrate the types of uses and disclosures we may make without your authorization for payment, home care operations, and treatment.

• Payment. We use and disclose your PHI in order bill and collect payment for the services and items you may receive from us. We also may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your health information to bill you directly or services and items.
• Treatment. We may use and disclose your PHI to coordinate services with other health care providers involved in your care. For example, we may collect measurements to identify appropriate seating and mobility system(s). We may obtain and disclose information on CPT diagnosis codes, diagnosis and prognosis, functional limitations, pre-existing health conditions, hospitalizations, prior use of equipment, and information specific to qualifying the patient as dictated by CMN / detailed written order forms.
• Appointment Reminders. We may use and disclose your health information to contact you and remind you of visits / deliveries / to ask whether you need additional supplies.
• Release of information to Family / friends. We may release your health information to a friend or family member that is helping you to pay for your health care, or who assists in taking care of you.
• Disclosures Required by Law. We will use and disclose your health information when we are required to do so by federal, state or local law.

We require any business associates to protect the confidentiality of your information and to use the information only for the purpose for which the disclosure is made. We do not provide customer names and addresses to outside firms, organizations, or individuals except in furtherance of our business relationship with you or as otherwise allowed by law.

We restrict access to nonpublic information about you to those employees who need to know that information to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with federal standards to guard your personal information.

 

HIPAA Policy Statement - (cont.)

OTHER PERMITTED OR REQUIRED DISCLOSURES

• As Required by Law. We must disclose PHI about you when required to do so by law.
• Public Health Activities. We may disclose PHI to public health agencies for reasons such as preventing or controlling disease, injury, or disability. Victims of Abuse. Neglect, or Domestic Violence. We may disclose PHI to government agencies about abuse, neglect, or domestic violence.
• Health Oversight Activities. We may disclose PHI to government oversight agencies. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
• Judicial and Administrative Proceedings. We may disclose PHI in response to a court or administrative order. We may also disclose PHI about you in certain cases in response to a subpoena, discovery request, or other lawful process.
• Law Enforcement. We may disclose PHI under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
• To Avert a Serious Threat to Health or Safety. We may disclose PHI about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.
• Workers Compensation. We may disclose PHI to the extent necessary to comply with state law for workers’ compensation programs.

 

HIPAA Policy Statement - (cont.)

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION (PHI)

You have certain rights regarding PHI that we maintain about you.

• Right To Access Your PHI. You have the right to review or obtain copies of your PHI records, with some limited exceptions. Usually the records include referral information, delivery forms, billing, claims payment, and medical management records. Your access to records can include PHI maintained electronically even if not an electronic health record. Your request to review and/or obtain a copy of your PHI records must be made in writing. We may charge a fee for the costs of producing, copying, and mailing your requested information, but we will tell you the cost in advance.
• Right To Amend Your PHI. If you feel that PHI maintained by us is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by us, or you ask to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
• Right to Notification of Breach or Accounting of Disclosures. You have the right to be notified following a breach of your unsecured PHI. You may request an accounting of disclosures we have made of your PHI. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper or electronically). We may charge for providing the accounting, but we will tell you the cost in advance.
• Right To Request Restrictions on the Use and Disclosure of Your PHI. You have the right to request that we restrict or limit how we use or disclose your PHI for services, payment, or health care operations. You may restrict disclosures of PHI to a health plan if you have paid out-of-pocket in full for the health care item or service. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.
• Right To Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you or that we send information to a certain location. For example, you may ask that we contact you at work rather than at home. Your request to receive confidential communications must be made in writing. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice. You may ask us to give you a copy of this notice at any time.
• Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting our privacy Office.
• Complaints. If you believe that your privacy rights have been violated, you may file a complaint with us and/or with the Office of Civil Rights. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Updated: September 23, 2013

Please check the box below to indicate you have read the above statement.

(*)
Please check the box to proceed

Additional Authorized Contacts

Please list any people you are authorizing to discuss your account and/or medical conditions with us.
HIPAA Authorization

With whom can we discuss your information? Please enter their name(s) here (or leave blank).

 

Dependents

Please enter information for any dependents you'd like included with your account.

Enter full name - first, middle initial & last.

Full Name
Please type your first and last name.

DOB
Invalid Input

Gender
Invalid Input

Allergies
Invalid Input

(Leave blank if none)

Current Medications

Please list any medications - prescription or over the counter (OTC) - currently taken. You do not need to include prescriptions filled with us.
Current Medications
Please list any current medications

Current Medical Conditions

Please list any current medical conditions that will help our pharmacist understand your needs.
Current Medical Conditions
Please list any current medical conditions


Enter full name - first, middle initial & last.
Full Name
Please type your first and last name.

DOB
Invalid Input

Gender
Invalid Input

Allergies
Invalid Input

(Leave blank if none)

Current Medications

Please list any medications - prescription or over the counter (OTC) - currently taken. You do not need to include prescriptions filled with us.
Current Medications
Please list any current medications

Current Medical Conditions

Please list any current medical conditions that will help our pharmacist understand your needs.
Current Medical Conditions
Please list any current medical conditions


Enter full name - first, middle initial & last.
Full Name
Please type your first and last name.

DOB
Please enter a date

Gender
Invalid Input

Allergies
Invalid Input

(Leave blank if none)

Current Medications

Please list any medications - prescription or over the counter (OTC) - currently taken. You do not need to include prescriptions filled with us.
Current Medications
Please list any current medications

Current Medical Conditions

Please list any current medical conditions that will help our pharmacist understand your needs.
Current Medical Conditions
Please list any current medical conditions


Enter full name - first, middle initial & last.
Full Name
Please type your first and last name.

DOB
Please enter a date

Gender
Invalid Input

Allergies
Invalid Input

(Leave blank if none)

Current Medications

Please list any medications - prescription or over the counter (OTC) - currently taken. You do not need to include prescriptions filled with us.
Current Medications
Please list any current medications

Current Medical Conditions

Please list any current medical conditions that will help our pharmacist understand your needs.
Current Medical Conditions
Please list any current medical conditions


Enter full name - first, middle initial & last.
Full Name
Please type your first and last name.

DOB
Please enter a date

Gender
Invalid Input

Allergies
Invalid Input

(Leave blank if none)

Current Medications

Please list any medications - prescription or over the counter (OTC) - currently taken. You do not need to include prescriptions filled with us.
Current Medications
Please list any current medications

Current Medical Conditions

Please list any current medical conditions that will help our pharmacist understand your needs.
Current Medical Conditions
Please list any current medical conditions

Copayment Information

If a co-payment is required by your employer, please indicate how you would like to pay. If paying by check or money order we will bill you monthly. (If paying by credit card please call 888.778.8667 with your credit card number and your prescriptions will be charged to your card account. Do not enter credit card information here.)
I will pay for my prescriptions:(*)

Please select one

Comments
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Speak with a Pharmacist

Monday-Friday 8:30am-5pm (Eastern time zone)
888.778.8667 Toll-free
802.388.1684
Automated refills available

24/7 online and by calling

Contact Us

Orders/Refills: 888.778.8667 Toll-free
Automated Refill Line: 866.926.3667 Toll-free
Fax: 800.926.8138 Toll-free
Fax: 802.388.1688
Email: support@nemoprx.com

Address

New England Mail Order Pharmacy
PO Box 69
111 Maple Street
Middlebury, VT 05753

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