My Insurance Has Changed Form, My Kids Camp Meds

If your primary and/or secondary insurance has changed, please submit this form. If you have any questions, call us at 1 (951) 407-0707.

If you have a primary and secondary insurance, make sure to add both primary and secondary insurance information on the form, even if only one insurance has changed. This form will invalidate the previous insurance information you submitted.

Please be aware, in the case your new insurance denies the charges, we reserve the right to charge your credit card for the full cost of medication. All credit card charges from the Perris Hills Pharmacy will appear as a separate charge after your child returns from camp.

Download the PDF version of My Insurance Has Changed here.

PARENT OR LEGAL GUARDIAN INFO

First name: (required)

Last name: (required)

Email: (required)

Home phone number: (required)

Mobile number: (required)

MY CAMPER'S INFO

The information of the child going to camp

First name: (required)

Last name: (required)

Date of Birth: (required)

Month

Day

Year

INSURANCE INFORMATION

Please leave fields blank that do not apply.

Primary Insurance

Insured full name:

Insurance name:

Insurance phone #:

Member ID:

Rx BIN:

Rx PCN:

Rx GROUP:

Do you have secondary insurance?

Secondary Insurance

Insured full name:

Insurance name:

Insurance phone #:

Member ID:

Rx BIN:

Rx PCN:

Rx GROUP:

A G R E E M E N T
By clicking "Submit" you agree to Perris Hills Pharmacy's, My Kids Camp Meds TERMS OF USE and PRIVACY POLICY AGREEMENT.

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