Order Form - Expatriate Prescription Service

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concierge@expatps.com

EPS Order Form

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Order Form

Insurance Information
Policy Holder Member ID
Insurance Company Name
Policy Holder Name
Group or Employer Name
Order Information
- A signed prescription from a licensed physician is required.
- All patient information must match prescription(s).
- Prescriptions should be written in English.
- Generic medications will be supplied, unless specified on the prescription.
- Medications are shipped in original manufacturers' packaging, sometimes resulting in a slightly higher quantity than prescribed.
*EPS will make every attempt to coordinate between you and your health care provider to gather necessary information. Please note that you may be asked to contact your health care provider before an order is processed.

Please become familiar with customs regulations and requirements in your country. It is the member’s responsibility to know if medications are able to be shipped into the country. EPS is not responsible for customs fees or for a package that spoils due to a member's refusal to pay customs fees. Any applicable customs fees will be the responsibility of the member unless your employer states otherwise.
Shipping Address
Street Address Address Line 2 City State / Province / Region
Primary Phone Number
Please provide country code first then number with area code.
Example: +1-000-000-0000
Secondary Phone Number
Please provide country code first then number with area code.
Example: +1-000-000-0000
Email Address*
Special Delivery Instructions
Patient 1 Information
Patient Name
First
Patient Date of Birth
Month
Day
Year
Allergies
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply
This field is hidden when viewing the form
Add Patient 2
Add Patient 2:8
- Add Another Patient
Patient 2 Information
Patient Name
First
Patient Date of Birth
Month
Day
Year
Allergies
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply
This field is hidden when viewing the form
Add Patient 3
Add Patient 3:8
- Add Another Patient
Patient 3 Information
Patient Name
First
Patient Date of Birth
Month
Day
Year
Allergies
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply
This field is hidden when viewing the form
Add Patient 4
Add Patient 4:8
- Add Another Patient
Patient 4 Information
Patient Name
First
Patient Date of Birth
Month
Day
Year
Allergies
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply
This field is hidden when viewing the form
Add Patient 5
Add Patient 5:8
- Add Another Patient
Patient 5 Information
Patient Name
First
Patient Date of Birth
Month
Day
Year
Allergies
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply
This field is hidden when viewing the form
Add Patient 6
Add Patient 6:8
- Add Another Patient
Patient 6 Information
Patient Name
First
Patient Date of Birth
Month
Day
Year
Allergies
Medications
Use the plus icon on the right to add more medications.
Name of Medication Strength Needed # of Pills / Doses Taken Per Day Desired Day Supply
This field is hidden when viewing the form
Need more patients or medications?
If you need to add more than 6 patients to this order please fill out an additional form or feel free to contact us.
Prescription Files
If you have any trouble uploading your prescription files, please email them to concierge@expatps.com.
Upload Prescriptions
Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, xls, csv, Max. file size: 8 MB.
You can upload multiple prescriptions here. Allowed files: jpg, jpeg, png, pdf, doc, csv, xls up to 8MB total.
Terms & Conditions
By checking this box, I agree to the following:*
- - The above information is complete and accurate. Any incorrect information may cause delays in the processing and delivery of my order.
  - EPS is not responsible for lost or damaged packages. According to Federal law, prescription medications cannot be returned, therefore, EPS is not obligated to accept the return of any goods.
  - EPS is not liable for customs fees or any customs-related delays.
  - By submitting your order, you authorize release of all information pertaining to my order and any claims to the appropriate plan administrator, underwriter, and/or sponsor in accordance with the Health Insurance Portability and Accessibility Act (HIPAA).
  - As a condition to and in consideration of your ability to utilize the Expatriate Prescription Services, you agree that Universal Rx shall have the authority to release (by telephone, fax, and/or e-mail using the Internet) any and all information which you provide, of any nature whatsoever, such as generic or particular personal health information, including, but not limited to, information relating to any physical and mental conditions (including, if applicable, AIDS test results, HIV status, genetic information, and psychiatric and substance abuse records/information) to the appropriate supplier(s), for the purposes of procuring medications on your behalf, even if medications are not ultimately procured.
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EPS Order Form

Insurance Information

Order Information

Patient 1 Information

Add Patient 2

Patient 2 Information

Add Patient 3

Patient 3 Information

Add Patient 4

Patient 4 Information

Add Patient 5

Patient 5 Information

Add Patient 6

Patient 6 Information

Need more patients or medications?

Prescription Files

Terms & Conditions

Quick Links

Contact

Name of Medication	Strength Needed	# of Pills / Doses Taken Per Day	Desired Day Supply