c9zu73mg7b7.typeform.com
Open in
urlscan Pro
44.214.231.15
Public Scan
URL:
https://c9zu73mg7b7.typeform.com/to/JWp4UlRJ
Submission: On September 13 via manual from US — Scanned from US
Submission: On September 13 via manual from US — Scanned from US
Form analysis
0 forms found in the DOMText Content
Question 1 1 Hello! Welcome to brightscrip pharmacy registration. brightscrip is a copay processor exclusively for copay assistance programs using BIN 022816. brightscrip is owned and operated by Monarch Specialty Group, LLC. We built and operate our own claims processor and pay pharmacies directly through ACH. Please complete the following information for us to configure your pharmacy for payment and reporting setup. What's your pharmacy NPI?This question is required.* OK press Enter ↵ Question 2 2 Is this a new setup or change to existing bank account on file?This question is required.* * KeyA New * KeyB Change to Existing OK press Enter ↵ Powered by Typeform