Form Pd903991 - Medco Pharmacy Mail-Order Form
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4Medco Pharmacy™
MAIL-ORDER FORM
Customer information:
1
Please verify or provide customer information below.
Please send me e-mail notices about the status of the
Subscriber #:
enclosed prescription(s) and online ordering at:
Rx Grp #:
@
.
(located under the logo on your ID card)
New shipping address:
Name:
Street Address:
Street Address:
(Medco will keep this address on file for all orders from this
Street Address:
subscriber until another shipping address is provided by any
City, ST, ZIP:
person in this plan.)
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 one envelope.
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to subscriber
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 subscriber
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
Complete your order:
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You can pay by e-check, check, money order, or credit card. Make checks
and money orders payable to Medco Health Solutions, Inc., and write your subscriber ID number
on the front. You can enroll for e-check payments and price medications by calling 1-800-948-8779.
Number of prescriptions sent with this order:
Payment options:
e-check
Payment enclosed
Credit card
Send bill
Credit card number
For credit card payments:
Visa
MC
Discover
AmEx
Diners
Expiration date
I authorize Medco to charge this card for all
orders from any person in this plan.
X
M M Y Y
Cardholder signature
Rush the mailing of this shipment ($15, 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.
PD903991
7/10
X00000-00000-000-0000 7/06
Mailing instructions are provided on the back of this form.
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Parent category: Business