Home Delivery Order Form
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3*6101*
HOME DELIVERY
ORDER FORM
1
Member information: Please verify or provide member information below.
Please send me e-mail notices about the status of the enclosed
Member ID:
prescription(s) and online ordering at:
Group:
@
.
Name:
New shipping address:
Street Address:
Street Address:
Street Address:
(Express Scripts will keep this address on file for all orders from
City, ST, ZIP:
this membership until another shipping address is provided by
any person in this membership.)
Daytime phone:
Evening phone:
2
Patient/doctor information: Complete one section for each person with a prescription. If a person has
prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on
back). Send all prescriptions in the envelope provided.
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
3
Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and money orders
payable to Express Scripts, and write your member ID number on the front. You can enroll for e-check payments
and price medications at , or call the Member Services phone number found on your ID card.
Number of prescriptions sent with this order:
Payment options:
e-check
Payment enclosed
Credit card
Send bill
For credit card payments:
Credit card number
Visa
MC
Discover
Amex
Diners
Expiration date
X
I authorize Express Scripts to charge this card for
all orders from any person in this membership.
M M Y Y
Cardholder signature
Rush the mailing of this shipment ($21, cost subject to change). NOTE: This will only rush the shipping,
not the processing of your order. Street address is required; P.O. box is not allowed.
DODMOFWB
Mailing instructions are provided on the back of this form.
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