Form Hb906472 - Medical Mutual Medco By Mail Order Form
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1
2Medco By Mail Order Form
Benefits Provided by Medical Mutual
For New Prescriptions
not complete the Patient Information section for refills.
Fill out one line of the Patient Information section for each new
For All Mail Orders
prescription you send. Be sure to include the patient’s full name,
Place all prescriptions and refill slips together with this
date of birth, and address, along with the doctor’s name and
completed order form and your copayment in the enclosed
phone number.
return envelope. Be sure to fold the form as indicated so the
For Refills
address on the bottom right shows through the window.
To order from our website: Have your member ID
If You Need Additional Help
number and prescription (Rx) number on hand. Your 12-digit
Call Member Services at 800/417-1961. The best times to call
prescription or Rx number can be found on your refill slip.
are Tuesday through Friday afternoons.
To order by phone: Call 800/4REFILL (800/473-3455) to use the
See the back of this form for additional instructions.
automated refill system. Have your member ID number and your
refill slip with the prescription information ready.
To order by mail: Include your refill slip(s) with this form. Do
Member Information
Please send me e-mail notices about the status of the enclosed
Member ID:
prescription(s) and online ordering at:
Group:
@
.
Name:
Shipping address if different from your mailing address
Street Address:
Check if:
Temporary
Permanent
Street Address:
Street Address:
City, ST, ZIP:
Daytime telephone
Evening telephone
Patient Information ––
complete one line for each patient (Do not complete for refills)
Does patient
Patient name and Medicare B
Patient’s relation to plan
Birth date
Doctor name
have any other
number (if applicable)
member (fill in one)
Sex
M/D/YYYY
and phone number
prescription plan?
1
Self
Spouse
Dependent
M
Yes
/
/
F
No
2
Self
Spouse
Dependent
M
Yes
/
/
F
No
3
Self
Spouse
Dependent
M
Yes
/
/
F
No
Order Information
Paying by Credit or debit Card?
Paying by Credit Car
d?
Visa
MC
Disc/NOVUS
AmEx
Diners
Total number of medications in this order
(including all refills and new medications)
CREDIT CARD NUMBER
X
M
Y
Subtotal of this order
$
.
EXPIRATION DATE
CARDHOLDER SIGNATURE
Optional expedited shipping
.
Check here to have all orders billed to your credit or debit card.
$9.00 (subject to change)
By doing so, you authorize Medco to keep your card number on file
and bill all future orders and any outstanding balances directly to your
Total enclosed
$
.
credit or debit card. To enroll by phone, please call 800/948-8779.
(do not send cash)
PLEASE NOTE: If you do not include payment (either by credit or debit card or by
check or money order) with your order, your order may be delayed and you may be
contacted for payment prior to the processing of your order.
Paying by check or money order? Write your member ID, for refills
include your Rx#, and for new prescriptions, include the cardholders first
Please be sure address
and last name on your check or money order. All checks and money orders
is visible through window
should be made payable to Medco.
of return envelope.
MEDCO
P O BOX 182050
COLUMBUS OH 43218-2050
!4321820505!
FORM #HB906472
MMO#Z5287
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Parent category: Business