Fillable Mail Service Order Form

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Mail Service Order Form

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The Mail Service Order Form form is 2 pages long and contains:

  • 0 signatures
  • 55 check-boxes
  • 69 other fields

Country of origin: OTHERS
File type: PDF

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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
StateZIP Code
Daytime Phone #: Evening Phone #:
Last Name First NameMISuffix (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.
©2020 CVS Caremark. All rights reserved. P13-N
Mail Service Order Form
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.
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
PO BOX 659541
SAN ANTONIO, TX 78265-9541
rpsrrsqqssqrrrsrrsrrsqqrrrqprrpqprrppsrrqqsrsprsqspsrsprpqrprpqrs
RESET FORM
PRINT FORM
.
Spanish forms and labels
Allergies:
Special instructions:
Credit or debit card. (VISA
®
, MasterCard
®
, Discover
®
, or American Express
®
)
Check or money order. Amount: $
C
D
E
Spanish forms and labels
ErythromycinCephalosporin CodeineAspirinNone
Sulfa Other:
Peanuts
Arthritis AsthmaDiabetes Acid reflux Glaucoma
High blood pressure
Other:
High cholesterol Migraine Osteoporosis Prostate issues
Penicillin
Heart problem
Thyroid
Gender: MF
Date new prescription written:
Doctor’s last nameDoctor’s first nameDoctor’s phone #
Allergies:
ErythromycinCephalosporin CodeineAspirinNone
Sulfa Other:
Peanuts
Arthritis AsthmaDiabetes Acid reflux Glaucoma
High blood pressure
Other:
High cholesterol Migraine Osteoporosis Prostate issues
Penicillin
Heart problem
Thyroid
Gender: MF
Date new prescription written:
Doctor’s last nameDoctor’s first nameDoctor’s phone #
Fill in this oval if you DO NOT want us to use this payment
method for future orders.
2nd business day ($17)
Next business day ($23)
Credit card holder signature/Date
Suffix
(JR,SR)
Suffix
(JR,SR)
Date of birth:
Last Name
Nickname
Nickname
First Name
MI
Last Name First Name
MI
Date of birth:
MM-DD-YYYY
MM-DD-YYYY
MMYY
Exp.Date
Tell us about new health information for 1st person if never provided or if changed.
Medical conditions:
Tell us about new health information for 2nd person if never provided or if changed.
Medical conditions:
Electronic check. Pay from your bank account. (You must first register online or call Customer Care.)
How would you like to pay for this order?
(If your copay is $0, you do not need to provide payment information.)
E-mail address:
E-mail address:
Tell us about the people ordering prescriptions. If there are more than two people, please complete another form.
First person with a refill or new prescription.
Use your card on file.
Use a new card or update your card’s expiration date.
Second person with a refill or new prescription.
Regular delivery is free and takes up to 5
days after your order is processed.
If you want faster delivery, choose:
Faster delivery
can only be
sent to a
street address,
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)
MOF WEB 0316 SAT
• Make check or money order payable to CVS Caremark.
• Write your prescription benet 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.
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Mail Service Order Form

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Completed 2 March 2021

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