Form He58918 - Highmark Blue Shield Medco By Mail Order Form
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1
2Medco By Mail Order Form
Benefits Provided by Highmark Blue Shield
Member Information
Member ID: _____________________________
Shipping address if different from your mailing
Group:
PD1 HMRK001
address
Name: ________________________________
Check if
o Temporary
o Permanent
Street Address: __________________________
Street Address: __________________________
Street Address: __________________________
City, ST, ZIP: ____________________________
You authorize release of all information to
Daytime telephone
the plan administrator, underwriter, sponsor,
and their agents for use in connection with
Evening telephone
the benefit plan programs. Information may
also be used for other reporting and analysis
purposes without identification of you or
your family members.
Patient Information—complete one line for each new prescription (Do not complete for refills)
Patient name and
Patient’s relation to
Doctor name
Does patient
Medicare B number plan member
Birth date
and phone
have any other
(if applicable)
(fill in one)
Sex
M/D/YYYY
number
prescription plan?
❏ Self ❏ Spouse
❏ M
❏
1
Yes
/
/
❏ Dependent
❏ F
❏
No
❏ Self ❏ Spouse
❏ M
❏
2
Yes
/
/
❏ Dependent
❏ F
❏
No
❏ Self ❏ Spouse
❏ M
❏
3
Yes
/
/
❏ Dependent
❏ F
❏
No
Order Information
Total number of medications in this order
Check here to have all orders billed to
(including all refills and new medications)
your credit card.
By doing so, you authorize Medco to keep
Subtotal of this order
$
.
your card number on file and bill all future
orders directly to your credit card. To enroll
.
Optional expedited shipping
by phone, please call 1 800 948-8779.
$15.00 (subject to change)
$
.
Paying by check? Write your member ID
Total enclosed
number on your check or money order made
(do not send cash)
payable to Medco.
Paying by Credit Card?
Visa
MC
(information continued on back side)
Disc/NOVUS
AmEx
Diners
CREDIT CARD NUMBER
MEDCO HEALTH SOLUTIONS OF FORT WORTH
M
Y
X
PO BOX 650022
DALLAS TX 75265-9867
EXPIRATION DATE
CARDHOLDER SIGNATURE
!7526598675!
FORM #HE58918
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Parent category: Business