Prescription Drug and Medical Provider Form

Please download, save and complete the form below and submit to help us provide you with the best information available. NOTE: If you have more than 10 prescriptions or 8 Providers, please submit a second form with the remaining information.

INSTRUCTIONS ON HOW TO DOWNLOAD THE PRESCRIPTION DRUG & MEDICAL PROVIDER FORM

To download a copy of the Prescription & Medical Provider Form to complete offline, click the link below and save it to your computer. Please save as 2024MMDDYY_YOURLASTNAME_2024DrugForm

2024-Prescription-Drug-Form

When you have completed updating your form, attach and email it directly to:

Debra Bivens at  Debra@Insure-Texas.com

If you completed a second form, be sure to attach both pages as they are created as separate forms. 

You may email your prescription drug and medical information to us:

Email us at: Debra@Insure-Texas.com

Debra Bivens
Agent/Broker