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New Patients: Register online to help expedite service!

Welcome to Cardinal Health Specialty Pharmacy. New patients can register by completing all sections below. To start, select the name of the medication that you have been prescribed. Only one registration is needed per patient even if you have been prescribed multiple drugs.

Select Drug

The name of the medication is required to register online. Please call your prescriber to obtain the name of your medication.

Call Cardinal Health Specialty Pharmacy at 888-662-6779 if your medication is not listed as an option. We’re available Monday – Friday from 8:00 AM to 8:00 PM ET.

General

Please review the following instructions and guidelines regarding your prescription.

Complete the following section with the patient’s full demographic information and pharmacy insurance information.

Call us at 888-662-6779 with any questions. We’re available Monday – Friday from 8:00 AM to 8:00 PM ET.

General

Please review the following instructions and guidelines regarding your prescription.

Complete the following section with the patient’s full demographic information and pharmacy insurance information.

CHSP will contact you by phone once the enrollment is complete and a prescription is received from your prescriber.

Government Insurance & HSA/HRA

This medication is automatically eligible for co-pay assistance for commercially insured patients only. Co-pay savings are not available for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.

Please inform us prior to delivery if your pharmacy insurance plan is linked to a health reimbursement account or health savings card.

Uninsured or cash-paying patients are not eligible for copay savings.

Call us at 844-445-2338 with any questions. We’re available Monday – Friday from 8:00 AM to 8:00 PM ET.

Government Insurance & HSA/HRA

This medication is automatically eligible for co-pay assistance for commercially insured patients only. Co-pay savings are not available for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.

Please inform us prior to delivery if your pharmacy insurance plan is linked to a health reimbursement account or health savings card.

Uninsured patients are eligible to fill this medication at a discounted cash price.

Call us at 844-447-1783 with any questions. We’re available Monday – Friday from 8:00 AM to 8:00 PM ET.

Government Insurance & HSA/HRA

This medication is automatically eligible for co-pay assistance for commercially insured patients only. Co-pay savings are not available for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.

Please inform us prior to delivery if your pharmacy insurance plan is linked to a health reimbursement account or health savings card.

Uninsured patients are eligible to fill this medication at a discounted cash price.
Co-pay savings are not eligible for any person that is 65 years of age or older without commercial insurance and for permanent residents of Massachusetts or Minnesota.
All eligible patients must register for a Copay Card to receive cost savings on their medication. Enter the copay card information in the secondary pharmacy insurance field.

Call us at 888-963-3748 with any questions. We’re available Monday – Friday from 8:00 AM to 8:00 PM ET.

Government Insurance & HSA/HRA

This medication is automatically eligible for co-pay assistance for commercially insured patients only. Co-pay savings are not available for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.

Please inform us prior to delivery if your pharmacy insurance plan is linked to a health reimbursement account or health savings card.

Co-pay savings are not eligible for any person without commercial insurance and for permanent residents of Massachusetts.

Call us at 866-541-6319 with any questions. We’re available Monday – Friday from 8:00 AM to 8:00 PM ET.

PATIENT INFORMATION

First Name

Middle Name

Last Name

(Please enter your legal name or the name your prescriber and pharmacy insurance have on file)

Date of Birth

(MM/DD/YYYY) *

Gender *

MaleFemale

Address

Apt No

City

State

Zip

I would like my medication to be shipped to the address listed above

YesNo

If No, I would like my medication shipped to the following address:

Address

Apt No

City

State

Zip

Special Delivery Instructions

Preferred phone number to contact me

Cell

Home

The pharmacy can contact me via text

YesNo

The pharmacy can contact me via email

YesNo

PHARMACY INSURANCE INFORMATION (Please provide the information from your prescription drug benefits)

Prescription Insurance Type

Commercial/Private insuranceMedicare Part D/MedicaidNo Insurance/Cash Patient

Name of Pharmacy Insurance Company

Member ID number

Rx BIN

Rx PCN

Rx Group No

Relationship

SubscriberDependent

Person Code

Upload insurance card (front)

(Only upload insurance information. We cannot accept prescriptions sent from patients.)

Upload insurance card (back)

Do you have additional secondary drug insurance benefits or co-pay assistance information?

YesNo

Prescription Insurance Type

Commercial/Private insuranceMedicare Part D/Medicaid

Name of Pharmacy Insurance Company

Member ID number

Rx BIN

Rx PCN

Rx Group No

Relationship

SubscriberDependent

Person Code

Upload insurance card (front)

Upload insurance card (back)

PRESCRIBER & THERAPY INFORMATION

Healthcare Provider Name

Healthcare Provider Phone Number

My healthcare provider is prescribing a drug to treat my...

This medication is a...

ADDITIONAL INFORMATION

Allergies and Reactions

(If there aren’t any drug allergies, enter NKA)

Current Weight

lbs

Current Medications

(If there aren’t any current medications, enter None)

Current/ Past Medical Conditions

(If there aren’t any current/ past medical conditions, enter None)

Emergency Contact

Name

Relationship

Phone No

Authorization to Automatically Ship when Registration and Prescription(s) are received:

By checking this box, I authorize Cardinal Health Specialty Pharmacy (CHSP) to process the prescribed drug(s) through my active insurance and ship to the provided shipping address. I certify that the information contained herein is true, complete, and accurate. I understand CHSP will only contact me if the required information is incomplete.

Offer to counsel (We will call to offer counseling by a Pharmacist if not checked)

I decline the offer of counseling by the pharmacist on the initial fill of this prescription. If I have questions concerning this prescription, I am aware that a pharmacist is available to answer these questions at 844-445-2338.

Offer to counsel (We will call to offer counseling by a Pharmacist if not checked)

Notice of Privacy Practices

The privacy and the security of personal information are very important to us. If you have any questions or concerns about how we protect your privacy and the privacy of others, read our site's Privacy Policy, and our HIPAA Policy.

I acknowledge I have reviewed Patient Privacy and HIPAA policies.

By checking this box, I understand that all medication deliveries are final and returns are not accepted.

I certify that the information that I provided is true and correct to the best of my knowledge.

Please review all entries for accuracy and completion and submit below.

Commercial/Private insurance

Patient is qualified for the MFG copay assistance programs.

Medicare Part D/Medicaid

Patient does not qualify for MFG copay assistance programs.

Confirmation

Are you sure you wish to proceed? Click on OK to continue with enrollment.

Click on Cancel to review the page again.

Enrollment Successful

Thank you for submitting your information. We will contact you in a timely manner when received.

Did you know we have an online patient portal? Click on About my patient account to learn more. You will be able to create your account after you receive your first delivery.

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