This form is used to provide a copy of pharmacy Member ID Card information
by email to the member specified below. The transmission of this email
copy is contingent upon verification of identity. This card copy does not
certify eligibility, guarantee payment, or fully reflect the plan's
limitations. The card will not reflect your medical benefits information.
Please contact your benefits department for your medical benefits
By submitting this form, I agree to receive my pharmacy Member ID Card
Information through the email provided on this sheet and certify that I
am the member specified above.