Medication Order Form - Aetna Page 2
Download a blank fillable Medication Order Form - Aetna in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medication Order Form - Aetna with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2C
Tell us about the people getting prescriptions. If there are more than two people, please complete another form.
1st person with a refill or new prescription. This person needs:
Spanish forms and labels
Last Name
First Name
MI
Suffix
(JR,SR)
Nickname
Date of Birth:
Gender:
M
F
MM-DD-YYYY
Your E-Mail:
Date new prescription written:
Doctor’s Last Name
Doctor’s First Name
Doctor’s Phone #
Tell us about new allergies or health information for this person. Only tell us about new information.
Allergies:
None
Aspirin
Cephalosporin
Codeine
Erythromycin
Peanuts
Penicillin
Sulfa
Other:
Health Information:
Arthritis
Asthma
Diabetes
Acid Reflux
Glaucoma
Heart Problem
High Blood Pressure
High Cholesterol
Migraine
Osteoporosis
Prostate Issues
Thyroid
Other:
2nd person with a refill or new prescription. This person needs:
Spanish forms and labels
MI
Last Name
First Name
Suffix
(JR,SR)
Nickname
Date of Birth:
Gender:
M
F
MM-DD-YYYY
Your E-Mail:
Date new prescription written:
Doctor’s Last Name
Doctor’s First Name
Doctor’s Phone #
Tell us about new allergies or health information for this person. Only tell us about new information.
Allergies:
None
Aspirin
Cephalosporin
Codeine
Erythromycin
Peanuts
Penicillin
Sulfa
Other:
Health Information:
Arthritis
Asthma
Diabetes
Acid Reflux
Glaucoma
Heart Problem
High Blood Pressure
High Cholesterol
Migraine
Osteoporosis
Prostate Issues
Thyroid
Other:
D
Special Instructions:
E
How would you like to pay for this order? Fill in the oval to choose a payment.
Electronic Check. Pay from your bank account. First time users register online or call Customer Care.
Bill Me Later
. Works like a credit card. First time users register online or call Customer Care.
®
Credit or Debit Card.
(VISA
, MasterCard
, Discover
, American Express
, including FSA/HRA/HSA debit cards)
®
®
®
®
Fill in this oval to use your card on file.
Fill in this oval to use a new card or to update your card expiration date.
Exp.Date
MMYY
Credit Card Holder Signature/Date
Check or Money Order. Amount: $
.
Regular delivery is free and will take 10 to 14
• Make check or money order out to Aetna Rx Home Delivery.
days from the day you send this form.
• Write your Aetna Member ID number on your check or
If you want faster delivery, choose:
money order.
2nd Business Day ($17)
Business days
• If your check is returned, we will charge you up to $40.
are only
Next Business Day ($23)
Monday-Friday
Payment for balance due and future orders: If you chose
• Faster delivery charges may change.
electronic check, Bill Me Later
, or a credit or debit card, we
®
• Faster delivery is for shipping time, not processing time.
will also use it to pay for any balance that you owe and for
• Faster delivery can only be sent to a street address,
future orders unless you provide another form of payment.
not a PO box.
Fill in this oval if you DO NOT want to use this payment
method for future orders.
Credit Card Disclaimer: I authorize Aetna Rx Home Delivery to bill my credit card. I understand that my credit card will be billed the
following amounts in effect at the time my order is filled: any applicable copayment(s), coinsurance and/or deductible(s), payments due for
any medications not covered under my benefit plan, plus any special shipping costs.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business