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MAIL ORDER FORM PLEASE PRINT CLEARLY. Enclose this form with your prescription(s) and co-payment(s). MEMBER INFORMATION CARDHOLDER NAME CARDHOLDER ID #DOB (MO/DAY/YR)SIMPLE TIPS TO SAFELY REDUCE YOUR

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How to fill out mail order prescription and

01

Contact your doctor for a prescription.

02

Find a mail-order pharmacy that accepts your insurance.

03

Provide your insurance information and prescription to the mail-order pharmacy.

04

Wait for your prescription to be processed and shipped to your home.

Who needs mail order prescription and?

01

Individuals who require medication on a regular basis.

02

People who have difficulty travelling to a physical pharmacy.

03

Patients who prefer the convenience of having medications delivered to their doorstep.

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What is mail order prescription and?

Mail order prescription is a method of obtaining prescription medications through the mail from a pharmacy.

Who is required to file mail order prescription and?

Pharmacies and healthcare providers are required to file mail order prescriptions.

How to fill out mail order prescription and?

Mail order prescriptions can be filled out online or through a paper order form provided by the pharmacy.

What is the purpose of mail order prescription and?

The purpose of mail order prescriptions is to provide convenient access to medications for patients who cannot physically visit a pharmacy.

What information must be reported on mail order prescription and?

Information such as patient name, medication prescribed, dosage instructions, and prescribing healthcare provider must be reported on mail order prescriptions.

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