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BJC Employee Pharmacy (mail order) Registration Form

**You must be a BJC Medical Plan Participant to use the BJC Employee Pharmacy**

Patient Information

First Name

Middle Initial

Last Name

<p><em>The name should exactly match the insurance card. Questions? Contact the BJC Employee Pharmacy (314) 525-0411</em></p>

Gender

Date of Birth

Insurance Member ID#

Preferred Phone Number

Secondary Phone Number

Preferred Email Address

Secondary Email Address

<p><em>If shipped USPS, you will receive an email notification with a tracking number when your medication ships.</em></p>

Medication Allergies

Other Allergies

Home/Billing Address

Street Address

City

State

ZIP Code

Shipping Address

Street Address

City

State

ZIP Code

<p><em>The pharmacy can only ship to addresses in Missouri and Illinois. Controlled substance (CII-V) and refrigerated medications cannot be mailed to a P.O. Box.</em></p>

Payment

The pharmacy accepts all major credit and debit card types (MasterCard, VISA, Discover and American Express), Flexible Spending Account Card, pre-paid card, or cash card through BJC Payroll. Once your profile is created, you will receive a confirmation email directing you to our secure site where you can provide your card information.

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