NEW APPLICATION RE-ENROLLMENT APPLICATION …

Tennessee CoverRx OptumRx, Inc. Box 2135 Mission, Kansas 66201 Fax: 1-800-424-5766 2019 OptumRx, Inc. Rev: March 2020 RACE (FOR TITLE VI PURPOSES): LANGUAGE SPOKEN (OPTIONAL) Black American Indian or Alaskan English White Asian or Pacific Islander Hispanic Other: Spanish Other: NEW APPLICATION RE-ENROLLMENT APPLICATION Please note: All fields must be completed (unless noted as optional). Please see above to mail or fax completed form. LAST NAME FIRST NAME MI GENDER DATE OF BIRTH SOCIAL SECURITY NUMBER EMAIL ADDRESS By signing below, you agree to receive CoverRx text-messages sent to the phone number listed above.

gender date of birth social security number . male female – – # of people in household yearly household income (please enter an amou nt) home phone number (write n/a if you do not have a phone). email address cell phone number (write n/a if you do not have a phone). by signing below, yo u agree to receive text-messages sent to the phone number listed above about coverrx.

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