MiRx: Michigan's prescription drug discount program.

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MiRx Application Enrollment Form

Last Name

First Name

Middle Initial

Date of Birth (MM/DD/YYYY)

Area Code

Phone Number

Extension

Address (Street Address or P.O. Box is Required)

Street Address

Street Address 2 (Apt, PO Box, etc.)

City

State

Zip Code

Other Household Members

Add names and birth dates of additional family members, if needed.

Last Name

First Name

Middle Initial

Date of Birth

Add Household Member

Other Household Members
Last Name	First Name	MI Middle Initial	DOB Date of Birth	Remove

I certify that my family meets the income limit for the MiRx discount card and we have no other prescription drug coverage.

Signature