Bill Anoatubby
Governor
Chickasaw Nation Pharmacy Refill Center
Chickasaw Nation Employee Prescription Benefit
Enrollment Form
Denotes a required field
Name:
Last
Middle
First
Suffix
Birth date:
Phone:
Cell
Home
SSN
APPLICANT INFORMATION
Gender
Marital status:
Native:
(mm/dd/yyyy)
Email
Mailing address:
City
State
ZIP
Physical address:
City
State
ZIP
NOTICES AND GUIDELINES
All participants must submit documentation below:
1. Copy of CDIB
2. Copy of tribal citizenship card
3. Copy of prescription insurance card, front and back
To submit required documentation at a later time,
please send copies to:
Chickasaw Nation Pharmacy Refill Center
933 N. Country Club Road
Ada, OK 74820
Local: 580-421-8725
Toll Free: 855-478-8725
Fax: 580-421-8701
Email: CNRefillCenter@chickasaw.net
If yes, please list:
ELIGIBILITY
SUPPORTING INFORMATION
Under penalty of law, I hereby understand and agree to all Conditions of Participation and guidelines of the program.
Applicant Signature:
(Type your name above)
Date:
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
A complete description of how your medical information will be used and disclosed by the Chickasaw Nation Pharmacy Refill Center is in our NOTICE OF PRIVACY PRACTICES. The notice is posted throughout our facility and you will be given a copy for your personal use.
I have received a copy of the Chickasaw Nation Refill Center Notice of Privacy Practices dated October 1, 2019.
View Notice of Privacy Practices
Approved medications will be provided at no cost to the patient.
I am enrolling on behalf of:
• Chickasaw Nation employees and dependents currently enrolled on the Chickasaw Nation Tribal Employee Medical/Rx Insurance Plan
(CN WebTPA/Cerpass Rx).
CHICKASAW NATION EMPLOYEE VERIFICATION
Name:
Middle
Suffix
Last
First
Birth date:
(mm/dd/yyyy)
Form no. 02905 TCH-RC 10/2019
5. Copy of DL/State ID
* if applicable
* if applicable
* Participants under 18 years of age need to have parent or legal guardian's valid ID on file.
CN Insurance Plan ID
(XXXXXXXXXXXX)
DL or State ID:
DL or State ID Number
(mm/dd/yyyy)
DL or State ID Exp. Date
Tribal affiliation
Other:
Tribal ID
Prescription and non-prescription medication allergies:
4. Copy of secondary prescription insurance card, front and back
* if applicable
Please indicate how you would like to receive your prescriptions:
I am the parent/legal guardian of the above applicant.
933 N. Country Club Road / Ada, OK 74820 / (580) 421-8725
Chickasaw Nation Pharmacy Refill Center
Chickasaw Nation Employee Prescription Benefit
View Conditions of Participation
*You must click the link above to review and agree to the Conditions of Participation before submitting this application.
Frequently Asked Questions
* Must submit a valid Driver’s License or State ID with application.