Mail Order Sign Up | Northern Light Pharmacy

Enrollment and Prescription

Street and Mailing Address

For questions and inquiries, please call (800) 639-8801, local at (207) 275-3300, or email.

Date of Birth (MM/DD/YY):

Sex:

First Name:

Last Name:

Middle Initial:

Street Address:

City:

State:

Zip:

Check this box if your street and mailing address are the same:

Mailing Address:

City:

State:

Zip:

Northern Light Pharmacy is currently licensed to mail prescriptions to Maine, New Hampshire, Connecticut and Florida. All shipments containing controlled medications will require a signature.

Alternate Mailing Address:

City:

State:

Zip:

Shipping Information

*Please note that processing may take up to 5 business days.

Refrigerated shipments will be expedited at no additional cost and can only be sent to a street address, not a P.O. Box.

Primary Insurance Cardholder Info

Primary Insurance ID #:

Other 3rd Party Insurance Cardholder Info

All information can be found on member's card.

Status:

Insurance Company Name:

Cardholder ID#:

Rx BIN #:

Rx PCN #:

Group #:

Contact Info *Please fill all fields*

Preferred Contact Method:

Phone:

Alternate Phone:

Email:

Auto-Refill Program

For your convenience, Northern Light Pharmacy Mail Order offers an auto-refill program to help manage prescriptions. A prescription is eligible for auto-refill if it is a long-term or maintenance medication with refills authorized by the prescriber. Not all medications qualify for the auto-refill program. If enrolled, medications that qualify for the auto-refill program will automatically be filled, charged to the credit card on file and shipped without having to contact the pharmacy or the prescriber for additional refills.

**Note: If you would like to enroll in the Auto-Refill Program, you must have a credit card on file even if the copay for the medication is $0.00.

Payments must be received before the prescriptions can be sent.

Payment Info

Please Call 207.275-3300 to provide us with your credit card number. Please note that your order will not ship without a credit card number on file.

Transfer Prescriptions vs. New Prescriptions

Transfer Prescriptions: You want us to contact your current pharmacy and transfer all of your active prescriptions with refills to Northern Light Pharmacy. If your current prescription is not written for a 90 day supply, we can fill the prescription now and then contact your prescriber to request a 90 day supply in the future OR we can contact your prescriber to change the current prescription to a 90 day supply before we fill it for you. Note the second option may cause delays.

New Prescription: You want us to contact your prescriber to obtain new prescriptions for all of your medications.

Please Select: Transfer Prescription or New Prescription:

Current Pharmacy Name:

Phone:

Your Prescriptions

Selecting NO in the Fill Now column means that you will call us each time you need a refill. If you are enrolled in the Auto-Refill Program, you must only make the initial call to have your prescription(s) filled.

Medication Name and Strength:

Rx #:

Prescriber's Name:

Prescriber's Phone:

Fill Now:

Permission

I authorize Northern Light Pharmacy to bill my credit card. I understand that my credit card will be billed the following amounts in effect at the time my order is filled.

Any applicable copayment(s)
Coinsurance and/or deductible(s)
Payment for any medication not covered under benefit plan
Any special shipping cost (e.g. out-of-state or expedited)

I give permission for Northern Light Pharmacy to contact me via automated messaging (phone or text message) to update me on the status of my order or to contact me about questions they may have to assist with filling my prescription(s).

I agree to the above statements.:

Pharmacy Staff

Notes for Pharmacy Staff:

Verification: