Birdi Medication Order Form 2026

1. Click ‘Get Form’ to open the Birdi Medication Order Form in the editor.
2. Begin by filling out the Member Information section. Use black or blue ink and CAPITAL LETTERS only. Enter your First Name, Last Name, Member ID, Suffix, Plan Name, Date of Birth, and Gender.
3. Indicate the Number of New Prescriptions and provide your Preferred Phone settings. Fill in your Mobile Phone and Shipping Address details accurately.
4. Complete the Billing Address section if it differs from the Shipping Address. Ensure all fields are filled correctly including City, State, and Zip Code.
5. In the Health Information section, list any Allergies or Health Conditions you may have. If none apply, check the corresponding box.
6. Provide your Physician's information including their Last Name, First Name, Phone number, and Fax number.
7. Fill out Payment Information carefully. Choose your payment method and enter necessary card details if applicable.
8. Review all sections for accuracy before signing in the Authorizations area to confirm consent for processing your order.

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