Good Samaritan Pharmacy Profile Form - SCL Health System 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the last name, first name, birthday, and sex. If applicable, check the box for child-proof caps and indicate if this is a change of address.
3. Complete the 'Shipping Address' fields including apartment or suite number, street address (no P.O. boxes), city, state, ZIP code, and contact numbers.
4. In the 'Insurance Information' section, provide your identification number and select your Cigna plan type by checking one of the options.
5. Fill in the 'Physician Information' with your physician's first and last name along with their phone number. List any health conditions and drug allergies as indicated.
6. Indicate whether you would like to receive a call from a pharmacist regarding your medications by selecting YES or NO.
7. Sign and date the form to certify that all information is correct and authorize release of information as required.
8. If applicable, complete the 'Method of Payment' section by providing credit card details and billing address. Ensure you understand the terms regarding prescription returns before signing.

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