Member information: Please verify or provide member information below.
(Express Scripts will keep this address on file for all orders from
this membership until another shipping address is provided by
any person in this membership.)
1
Patient/doctor information: Complete one section for each person with a prescription. If a person has
prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on
back). Send all prescriptions in the envelope provided.
2
Mailing instructions are provided on the back of this form.
FOLD HERE
FOLD HERE
Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and money orders
payable to Express Scripts, and write your member ID number on the front. You can enroll for e-check payments
and price medications at Express-Scripts.com, or call the Member Services phone number found on your ID card.
3
First name Last name
Doctor’s phone numberDoctor’s last name 1st initial
Patient’s relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent
MF
First name
Last name
Doctor’s phone numberDoctor’s last name 1st initial
Patient’s relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent
MF
For credit card payments:
Visa MC Discover Amex Diners
Payment options:
e-check Payment enclosed Credit card Send bill
Number of prescriptions sent with this order:
I authorize Express Scripts to charge this card for
all orders from any person in this membership.
Credit card number
Expiration date
M M
YY
Cardholder signature
X
MLRFOHNW
HOME DELIVERY
ORDER FORM
Evening phone:
Member ID:
Group:
Name:
Street Address:
Street Address:
Street Address:
City, ST, ZIP:
Daytime phone:
*6101*
Rush the mailing of this shipment ($21, cost subject to change). NOTE: This will only rush the shipping,
not the processing of your order. Street address is required; P.O. box is not allowed.
Please send me e-mail notices about the status of the enclosed
prescription(s) and online ordering at:
@.
New shipping address:
Place your prescription(s), this form, and your
payment in an envelope. Do not use staples
or paper clips.
Patient/doctor information continued
Important reminders and other information
FOLD HERE
FOLD HERE
Express Scripts will make all possible efforts, as
appropriate by law, to substitute generic formulations
of medication, unless you or your doctor specifically
directs otherwise.
Pennsylvania and Texas laws permit pharmacists to
substitute a less expensive generic equivalent for a
brand-name drug unless you or your doctor directs otherwise.
Check the box if you do not wish a less expensive
brand or generic drug.
Please note that this applies only to new prescriptions and to
any refills of that prescription.
For additional information or help, visit us at
Express-Scripts.com or call Member Services at the phone
number found on your ID card. TTY/TDD users should call
1.800.759.1089.
Federal law prohibits the return of dispensed controlled
substances.
Check that your doctor has prescribed the maximum days’
supply allowed by your plan (not a 30-day supply), plus
refills for up to 1 year, if appropriate. Also, ask your doctor
or pharmacist about safe, effective, and less expensive
generic drugs.
Complete the Health, Allergy & Medication Questionnaire.
There may be a limit to the balance that you can carry
on your account. If this order takes you over the limit, you
must include payment. Avoid delays in processing by using
e-checks or a credit card. (See Section 3 for details.)
If you are a Medicare Part B beneficiary AND have
private health insurance, check your prescription drug
benefit materials to determine the best way to get
Medicare Part B drugs and supplies. Or, call Member
Services at the phone number found on your ID card. To
verify Medicare Part B prescription coverage, call
Medicare at 1.800.633.4227.
First name Last name
Doctor’s phone numberDoctor’s last name 1st initial
Patient’s relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent
MF
First name Last name
Doctor’s phone numberDoctor’s last name 1st initial
Patient’s relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent
MF
MLRFOHNW
EXPRESS SCRIPTS
PO BOX 747000
CINCINNATI, OH 45274-7000
C
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