High Option Plan

SilverScript Forms

Enrollment Form: Complete this form if you would like to enroll in the SilverScript Prescription Drug Program.

Disenrollment Form: Complete this form if you would like to disenroll in the SilverScript Prescription Drug Program.

SilverScript Mail Order Prescription Form: Complete this patient profile/order form. Mail this form, along with your prescription(s) and payment.

SilverScript Medicare Part D: Prescription Claim Form: Complete this form to request reimbursement for your prescriptions.