Save time getting prescription medication you take regularly (like high
blood pressure or diabetes drugs) by getting up to 90-day supplies from
CVS Caremark Mail Service Pharmacy.
CVS Caremark
®
Mail
Service Pharmacy
We deliver
quality and
convenience.
Sign up today at Caremark.com.
Medications when you need them.
There’s no need to drive to the pharmacy each month. We deliver up to
90-day supplies by mail to your home, oce and even your vacation spot.
Your doctor can send us your rells directly to save you even more time.
Get worry-free shipping with every delivery.
You get the medication you need with no-cost shipping. Your prescription
is lled by a licensed pharmacist and checked for quality. Our packages
are discreet, secure and hold up in any weather.
Avoid missing a dose with rell reminders.
Need a reminder? We’ll send you a text message 10 days before every
rell to conrm your order, make changes or cancel at any time. Download
our mobile app to manage and track your prescriptions on your own time.
Three easy ways to
get started
Online
Register or sign in at
Caremark.com.
Phone
Call 1-888-624-1139,
24-hours a day, seven
days a week. Have your
member ID number ready
when you call.
Mail
Fill out and send in a mail
service form. Be sure
to include your original
prescription for up to a
90-day supply.
Your privacy is important to us. Our employees are trained regarding the appropriate way to
handle your private health information.
©2020 CVS Caremark. All rights reserved. 106-51798A 051120 FLY040026EO00
02731008
Please fold here
Please fold here
Please fold here
Please fold here
Reset Form
Print Form
®
Mail Service Order Form
Mail this form to:
Number of New prescriptions:
Number of Refill prescriptions:
New Prescriptions - Mail your new prescriptions with this form.
Refills - Order by Web, phone, or write in Rx number(s) below.
Refills. To order mail service refills, enter your prescription number(s) here.
A
B
Apt./Suite #
City
State ZIP Code
Daytime Phone #: Evening Phone #:
Last Name First Name MI Suffix (JR, SR)
1) 2) 3) 4)
5) 6) 7) 8)
Prescription Plan Sponsor or Company Name
Member ID # (if not shown or if different from above)
Street Address
Please use blue or black ink and print in capital letters. Fill in both sides of this form.
Instructions:
Use shipping address
for this order only.
Shipping Address. To ship to an address different from the one printed above, enter the changes here.
We may package all of these prescriptions together unless you tell us not to.
All claims for prescriptions submitted to CVS Caremark Mail Service Pharmacy using this form
will be submitted to your prescription benet plan for payment. If you do not want them submitted
to your plan, do not use this form. You may call Customer Care to make alternate arrangements
for submission of your order and payment.
©2019 CVS Caremark. All rights reserved. P13-N
-
-
-
-
-
CVS Caremark
PO BOX 94467
PALATINE, IL 60094-4467
ppqssqrrsprrssqrprrrrssrsqqsqqqpppsrssppqsqpspqrrrpqrrsprrpqsrppq
TO RECEIVE YOUR ORDER SOONER request refills or new prescriptions online at www.caremark.com
or call the toll-free number on your member ID card.
CVS Caremark wants to provide you with high quality medicines at the best possible price. In order to do
this, we will substitute equivalent generic medicines for brand name medicines whenever possible. If you
do not want us to substitute generics, please provide specic instructions, including drug names, in the
“Special Instructions” section of this form.
RESET FORM
PRINT FORM
Please fold here
Please fold here
Please fold here
Please fold here
* WEB *
C
Tell us about the people ordering prescriptions. If there are more than two people, please complete another form.
Spanish forms and labels
First person with a refill or new prescription.
Last Name First Name
MI
Gender: M
Suffix
(JR,SR)
Date of birth:
MM-DD-YYYY
F
Date new prescription written:
Doctor’s last name Doctor’s first name Doctor’s phone #
E-mail address:
Tell us about new health information for 1st person if never provided or if changed.
Allergies:
None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin
Sulfa Other:
Medical conditions:
Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problem
High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid
Other:
Second person with a refill or new prescription.
Spanish forms and labels
Last Name First Name
MI
Gender: M
Suffix
(JR,SR)
Date of birth:
MM-DD-YYYY
F
E-mail address:
Date new prescription written:
Doctor’s last name
Doctor’s first name Doctor’s phone #
Allergies:
ErythromycinCephalosporin
CodeineAspirinNone
Sulfa Other:
Peanuts
Arthritis Asthma Diabetes Acid reflux Glaucoma
High blood pressure
Other:
High cholesterol Migraine Osteoporosis Prostate issues
Penicillin
Heart problem
Thyroid
Tell us about new health information for 2nd person if never provided or if changed.
Medical conditions:
D
Special instructions:
How would you like to pay for this order?
(If your copay is $0, you do not need to provide payment information.)
Electronic check. Pay from your bank account. (You must first register online or call Customer Care.)
Credit or debit card. (VISA
®
, MasterCard
®
, Discover
®
, or American Express
®
)
Use your card on file.
Use a new card or update your card’s expiration date.
Exp.Date
MMYY
E
Check or money order. Amount: $
.
Make check or money order payable to CVS Caremark.
Write your prescription benet ID number on your
check or money order.
If your check is returned, we will charge you up to $40.
Payment for Balance Due and Future Orders: If you choose
electronic check or a credit or debit card, we will use it to pay
for any balance due and for future orders unless you provide
another form of payment.
Credit card holder signature/Date
Regular delivery is free and takes up to 5
days after your order is processed.
If you want faster delivery, choose:
Faster delivery
2nd business day ($17)
can only be
sent to a
street address,
Next business day ($23)
not a PO Box
Expected processing time from receipt of this form:
Refills: 1-2 days
New/renewed prescriptions: Within 5 days unless additional
information is needed from your doctor
(Charges subject to change)
Fill in this oval if you DO NOT want us to use this payment
method for future orders.
-
-
-
-
NICKNAME
NICKNAME
* WEB *
Nickname
Nickname
Credit card number
MOF WEB 0316 MTP