Mail Order Form
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The Medco Pharmacy is part of the
Medco Pharmacy
MAIL-ORDER FORM
Express Scripts family of pharmacies
1
Member Information
Please verify or provide member information below.
Please send me e-mail notices about the status of the
enclosed prescription(s) and online ordering at:
Member ID:
@
.
Group:
New Shipping Address
Name:
Street Address:
Street Address:
Street Address:
(Express Scripts will keep this address on file for all
City,ST,ZIP:
orders from 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
Domestic partner
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
Domestic partner
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 number on your member 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
I authorize Medco to charge this card for all
X
orders from any person in this membership.
Cardholder signature
M M Y Y
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.
Mailing instructions are provided on the back of this form.
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