Fillable Mail Service Order Form (John Hopkins Medicine Medicare Plan)

Fill Online, Printable, Fillable, Blank Mail Service Order Form (John Hopkins Medicine Medicare Plan) Form

Use Fill to complete blank online JOHN HOPKINS MEDICINE MEDICARE PLAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Mail Service Order Form (John Hopkins Medicine Medicare Plan)

On average this form takes 21 minutes to complete

The Mail Service Order Form (John Hopkins Medicine Medicare Plan) form is 2 pages long and contains:

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

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your John Hopkins Medicine Medicare Plan forms online.

BROWSE JOHN HOPKINS MEDICINE MEDICARE PLAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
®
Mail Service Order Form
Member ID # (if not shown or if different from above)
Mail this form to:
CVS Caremark
PO BOX 94467
PALATINE, IL 60094-4467
Prescription Plan Sponsor or Company Name
Instructions:
Please use blue or black ink and
print in capital letters. Fill in both sides of this form.
New Prescriptions – Mail your new prescriptions with this form.
Number of New prescriptions:
Refills – Order by Web, phone, or write in Rx number(s) below.
Number of Refill prescriptions:
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.
A
Shipping Address. To ship to an address different from the one printed above, enter the changes here.
Last Name First Name MI Suffix (JR, SR)
Street Address
Apt./Suite #
Use shipping address
for this order only.
City
Stat
e
ZIP Code
Daytime Phone #: Evening Phone #:
B
Refills.
To order mail service refills, enter your prescription number(s) here.
-
-
-
-
1) 2) 3) 4)
5) 6) 7) 8)
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.
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.
©2016 CVS Caremark. All rights reserved. P13-N
02631008
ppqssqrrsprrssqrprrrrssrsqqsqqqpppsrssppqsqpspqrrrpqrrsprrpqsrppq
.
C
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. Spanish forms and labels
Suffix
(JR,SR)
Gender: MFDate of birth:
E-mail address:
Date new prescription written:
Doctor’s last nameDoctor’s first nameDoctor’s phone #
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 AsthmaDiabetes 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
Suffix
(JR,SR)
Gender: MFDate of birth:
E-mail address: Date new prescription written:
Doctor’s last nameDoctor’s first nameDoctor’s phone #
Tell us about new health information for 2nd person if never provided or if changed.
Allergies:
None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin
Sulfa Other:
Medical conditions:
Arthritis AsthmaDiabetes Acid reflux Glaucoma Heart problem
High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid
Other:
D
Special instructions:
E
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
Credit card holder signature/Date
Check or money order. Amount: $
• 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.
Fill in this oval if you DO NOT want us to use this payment
method for future orders.
Regular delivery is free and takes up to 5
days after your order is processed.
If you want faster delivery, choose:
2nd business day ($17)
Next business day ($23)
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)
49-MOF 0316 MTP
02641008
5,120.00
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Mail Service Order Form (John Hopkins Medicine Medicare Plan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document