Have your prescriptions delivered at home through Intermountain Healthcare's prescription Home Delivery program. To enroll, please complete and submit the form below. After submitting, Intermountain Healthcare will contact you to determine your method of payment. 

You can also download a paper copy of the form and mail it us at: 

Intermountain Home Delivery Pharmacy
7268 So. Bingham Junction Blvd., Suite B1
Midvale, Utah 84047

Basic Information
 
 
Select a date from the calendar.
 
 
 
 
 
 
 
Insurance Information
ACKNOWLEDGEMENT

By electronically signing below, I acknowledge the following:

  • The information that I provided on this form is correct to the best of my knowledge
  • That Intermountain Home Delivery Pharmacy will substitute generic formulations of medication unless my prescriber indicates otherwise
  • That I may contact Intermountain Home Delivery Pharmacy to speak with a pharmacist about my medications

Note: typing your full name in the space below will signify an electronic signature



Thank you for enrolling in Intermountain Healthcare's prescription Home Delivery program.

Questions? Contact Us:

(801) 501-6910
(855) 779-3960

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