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 & Notice of Privacy Practices

Effective Date: December 31, 2016

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

About Us

In this Notice, we use terms like “we,” “us” or “our” to refer to New England Mail Order Pharmacy. (“NEMOP”), its pharmacists, employees, staff and other personnel. NEMOP follows the terms of this Notice and may share health information for treatment, payment, or healthcare operations purposes and for other purposes as described in this Notice.

Purpose of this Notice

This Notice describes how we may use and disclose your health information to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. This Notice also outlines our legal duties for protecting the privacy of your health information and explains your rights to have your health information protected. We will create a record of the services we provide you, and this record will include your health information. We need to maintain this information to ensure that you receive quality care and to meet certain legal requirements related to providing your care. We understand that your health information is personal, and we are committed to protecting your privacy and ensuring that your health information is not used inappropriately.

Our Responsibilities

We are required by law to maintain the privacy of your health information and to provide you notice of our legal duties and privacy practices with respect to your health information. We are also required to notify you of a breach of your unsecured health information. We will abide by the terms of this Notice.

 

HIPAA Policy Statement - (cont.)

How We May Use or Disclose Your Health Information

The following categories describe examples of the way we use and disclose health information without your written authorization:

For Treatment: We may use and disclose your health information to provide you with medical treatment or services. For example, we may contact you regarding medications, therapeutic substitution (e.g., the availability of generic products), counseling and drug utilization review (DUR), product recalls, re-fill reminders or disease state management. We may disclose your health information to another pharmacist or to your prescriber for the purpose of a consultation.

For Payment: We may use and disclose your health information to others so they will pay us or reimburse you for your treatment. For example, a bill may be sent to you, your insurance company, pharmacy benefit manager or another third-party payer. The bill may contain information that identifies you, your diagnosis, and treatment or prescription medication used in the course of treatment. We may tell your health plan about a prescription medication you are going to receive to obtain prior approval or to determine whether your health plan will cover the prescription medication.

For Healthcare Operations: We may use and disclose your health information in order to support our business activities. These uses and disclosures are necessary to run the mail service pharmacy and make sure our patients receive quality care. For example, we may use your health information for quality assessment activities, reviewing the competence and qualifications of the pharmacists providing treatment to you, and for other essential activities.

We may also disclose your health information to third-party “business associates” that perform various services on our behalf, such as auditing, legal, billing and collection services. In these cases, we will enter into a written agreement with the business associate to ensure they protect the privacy of your health information.

Individuals Involved in Your Care or Payment for Your Care and Notification: If you verbally agree to the use or disclosure and in certain other situations, we will make the following uses and disclosures of your health information. We may disclose to your family, friends, and anyone else you identify as involved in your medical care or who helps pay for your care health information relevant to that person’s involvement in your care or paying for your care. We may also make these disclosures after your death.

We may use or disclose your information to notify or assist in notifying a family member, personal representative or any other person responsible for your care regarding your general condition or death. We may also use or disclose your health information to disaster-relief organizations so that your family or other persons responsible for your care can be notified about your condition, status and location.

We are also allowed to the extent permitted by applicable law to use and disclose your health information without your authorization for the following purposes:

As Required by Law: We may use and disclose your health information when required to do so by federal, state or local law.

Judicial and Administrative Proceedings: If you are involved in a legal proceeding, we may disclose your health information in response to a court or administrative order. We may also release your health information in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Health Oversight Activities: We may use and disclose your health information to health oversight agencies for activities authorized by law. These oversight activities are necessary for the government to monitor the healthcare system, government benefit programs, compliance with government regulatory programs and compliance with civil rights laws.

 

HIPAA Policy Statement - (cont.)

Law Enforcement: We may disclose your health information, within limitations, to law enforcement officials for several different purposes:

  • To comply with a court order, warrant, subpoena, summons or other similar process
  • To identify or locate a suspect, fugitive, material witness or missing person
  • About the victim of a crime, if the victim agrees or we are unable to obtain the victim’s agreement
  • About a death we suspect may have resulted from criminal conduct
  • About criminal conduct we believe in good faith to have occurred on our premises
  • To report a crime not occurring on our premises; the nature of a crime; the location of a crime; and the identity, description and location of the individual who committed the crime, in an emergency situation

Public Health Activities: We may use and disclose your health information for public health activities, including the following:

  • To prevent or control disease, injury, or disability
  • To report births or deaths
  • To report child abuse or neglect
  • Activities related to the quality, safety or effectiveness of FDA-regulated products
  • To notify a person who may have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition as authorized by law
  • To notify an employer of findings concerning work-related illness or injury or general medical surveillance that the employer needs to comply with the law if you are provided notice of such disclosure

Serious Threat to Health or Safety: If there is a serious threat to your health and safety or the health and safety of the public or another person, we may use and disclose your health information to someone able to help prevent the threat or as necessary for law enforcement authorities to identify or apprehend an individual.

Organ/Tissue Donation: If you are an organ donor, we may use and disclose your health information to organizations that handle procurement, transplantation or banking of organs, eyes or tissues.

Coroners, Medical Examiners and Funeral Directors: We may use and disclose health information to a coroner or medical examiner. This disclosure may be necessary to identify a deceased person or determine the cause of death. We may also disclose health information, as necessary, to funeral directors to assist them in performing their duties.

Workers’ Compensation: We may disclose your health information as authorized by and to the extent necessary to comply with laws related to workers’ compensation or similar programs that provide benefits for work-related injuries or illness.

Victims of Abuse, Neglect or Domestic Violence: We may disclose health information to the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Military and Veterans Activities: If you are a member of the Armed Forces, we may disclose your health information to military command authorities. Health information about foreign military personnel may be disclosed to foreign military authorities.

National Security and Intelligence Activities: We may disclose your health information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose your health information to authorized federal officials so they may provide protective services for the President and others, including foreign heads of state.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official to assist them in providing you healthcare, protecting your health and safety or the health and safety of others, or for the safety of the correctional institution.

Research: We may use and disclose your health information for certain research activities without your written authorization. For example, we might use some of your health information to decide if we have enough patients to conduct a cancer research study. For certain research activities, an Institutional Review Board (IRB) or Privacy Board may approve uses and disclosures of your health information without your authorization.

Other Uses and Disclosures of Your Health Information that Require Written Authorization: Other uses and disclosures of your health information not covered by this Notice will be made only with your written authorization. Some examples include:

  • Psychotherapy Notes: We usually do not maintain psychotherapy notes about you. If we do, we will only use and disclose them with your written authorization except in limited situations.
  • Marketing: We may only use and disclose your health information for marketing purposes with your written authorization. This would include making treatment communications to you when we receive a financial benefit for doing so.
  • Sale of Your Health Information: We may sell your health information only with your written authorization.

If you authorize us to use or disclose your health information, you may revoke your authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information as specified by your revocation, except to the extent that we have taken action in reliance on your authorization.

 

HIPAA Policy Statement - (cont.)

Your Rights Regarding Your Health Information

You have the following rights regarding the health information we maintain about you:

Right to Request Restrictions: You have the right to request restrictions on how we use and disclose your health information for treatment, payment or healthcare operations. In most circumstances, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing and submit it to the Privacy Officer at the address in this notice. We are required to agree to a request that we restrict a disclosure made to a health plan for payment or healthcare operations purposes that is not otherwise required by law, if you, or someone other than the health plan on your behalf, paid for the service or item in question out-of-pocket in full.

Right to Request Confidential Communications: You have the right to request that we communicate with you in a certain manner or at a certain location regarding the services you receive from us. For example, you may ask that we only contact you at work or only by mail. To request confidential communications, you must make your request in writing and submit it the Privacy Officer at the address in this notice. We will not ask you the reason for your request. We will attempt to accommodate all reasonable requests.

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. To inspect and copy your health information, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer at the address in this notice. You may request access to your medical information in a certain electronic form and format if readily producible or, if not readily producible, in a mutually agreeable electronic form and format. Further, you may request in writing that we transmit a copy of your health information to any person or entity you designate. Your written, signed request must clearly identify such designated person or entity and where you would like us to send the copy. If you request a copy of your health information, we may charge a cost-based fee for the labor, supplies and postage required to meet your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed by a licensed healthcare professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that your health information is incorrect or incomplete, you may request that we amend your information. You have the right to request an amendment for as long as the information is kept by or for us. To request an amendment, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer at the address below.

We may deny your request for an amendment. If this occurs, you will be notified of the reason for the denial and given the opportunity to file a written statement of disagreement with us that will become part of your medical record.

Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures we make of your health information. Please note that certain disclosures need not be included in the accounting we provide to you.

To request an accounting of disclosures, you must make your request in writing by filling out the appropriate form provided by us and submitting it to the Privacy Officer at the address in this notice. Your request must state a time period which may not be longer than six years and which may not include dates before April 14, 2003. The first accounting you request within a 12-month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time, even if you previously agreed to receive this Notice electronically. To obtain a paper copy of this Notice, please contact the Privacy Officer at the address in this notice. You may also obtain a paper copy of this Notice at our website, www.nemoprx.com.

Changes to this Notice

We reserve the right to change the terms of this Notice at any time. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Each version of the Notice will have an effective date listed on the first page. Updates to this Notice are also available at our website, www.nemoprx.com.

Complaints

If you have any questions about this Notice or would like to file a complaint about our privacy practices, please direct your inquiries to the Privacy Officer at the address in this notice. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be retaliated against or penalized for filing a complaint.

Questions

If you have questions about this Notice, please contact the Privacy Officer at the address in this notice.

Privacy Officer
Serve You Rx Vermont, LLC
10201 West Innovation Drive, Suite 600, Milwaukee, WI 53226
Phone: 800-759-3203

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

NEMOP is committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. This Notice of Privacy Practices summarizes the ways we may use or disclose your health information and outlines your rights with regard to your health information. Please sign the form below to acknowledge that you have received our Notice of Privacy Practices.

I acknowledge that I have been given the opportunity to receive a copy of the Notice of Privacy Practices of NEMOP no later than the date I first obtained services from NEMOP, or if my first date of service was an emergency treatment situation, as soon as was reasonably practicable after the emergency treatment situation. I understand that if I have any questions regarding this Notice I may contact:

Privacy Officer
Serve You Rx Vermont, LLC
10201 West Innovation Drive, Suite 600, Milwaukee, WI 53226
Phone: 800-759-3203

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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