If you have been in a car accident and have an open no-fault claim you may be eligible to have your prescriptions filled at VascuScript and pay zero dollars out of pocket.* Please fill out the online forms prior to coming to the pharmacy to enable us to expedite and process your prescription order. Fax, mail, or bring in the completed forms with your prescriptions.

*Very few no-fault insurance companies require patient payment at the pharmacy and reimbursement directly to the patient from the insurance.

Click here to download writable PDF form

Instructions:
Completed forms may be submitted by E-mail.
Please follow these steps to E-mail completed the forms:
1. Complete fields in blue to the best of your ability.
2. Click “File” and choose “Save As”.
3. Save file to your Desktop
4. Using your E-mail client attach file and email to: info@vascuscript.com

Completed forms may be printed and:
Faxed to: 716-681-2270

Mailed to or dropped off:
VascuScript
2470 Walden Ave.
Suite 2400
Cheektowaga, NY 14225