Liberty Rx Plan

Printable Application

Use this to Fax or Mail in your application

Online Application Here

100% Secure

1. Print out the application
2. Complete the form
3. Mail or Fax it to the Team Liberty Benefits.
4. Your material packet and identification card(s) will arrive in 7 to 10 days.

1. Complete the online form.
2. You will receive an E-mail with a confirmation ID for your order.
3. Print out this Page
4. Call the phone number provided with your confirmation ID number.
5. Customer sales representative will assist you with any questions.
6. Mail or Fax the order form and receive your medication(s) in 7 to 10 Days