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Follow the instructions on Page 2 to complete this form. MEDCO CLIENT SERVICES TEAM ATTENTION EXXONMOBIL CONTACT FAX 972 852-9920 TELEPHONE NUMBER 800-497-4641 Use appropriate access number for the country you are calling from CHECK ONE Medco By Mail DATE PLEASE AUTHORIZE A -- DAY SUPPLY e.g. 365-DAY SUPPLY OF MEDICATION FOR EMPLOYEE S NAME DATE OF BIRTH PHYSICIAN S NAME/TELEPHONE Retail Pharmacy 5 MEDCO ID NAME OF MEDICATION/DRUG STRENGTH/QUANTITY DEPENDENT S NAME RELATIONSHIP MEDCO BY...
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