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. 

Also, in regards to the section of the form titled, "Pharmacy and Physician Information," we are happy to get your prescriptions transferred from your current pharmacy. If your prescriptions are out of refills, we request that you contact your doctor to request the medications. Please note that some doctor offices, as a means of protecting your Personal Health Information (PHI), request notice that you are switching pharmacies.

Intermountain Home Delivery Pharmacy

7268 So. Bingham Junction Blvd., Suite B1
Midvale, Utah 84047

For patient safety, one enrollment form is required for each patient.

Enroll Now

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Please use the date format MM/DD/YYYY (e.g. 11/28/1988)
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Gender

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Primary Phone Type

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Secondary Phone Type

Medication Allergies

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Pharmacy and Physician Information
If you require brand name medication, please write “BRAND NAME ONLY” following the specific medication and Rx Number. All medications listed below will be transferred to Intermountain Home Delivery. In the event that any prescriptions do not have sufficient refills, we ask that you speak to your doctor and request their office send a new prescription to the Home Delivery.
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Insurance Information
Acknowledgement
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