Fillable Prime-prescription-mail-order-form NEW_page 1

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Prime-prescription-mail-order-form NEW_page 1

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The Prime-prescription-mail-order-form NEW_page 1 form is 2 pages long and contains:

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  • 32 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Jacksonville University

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Physician/Prescriber’s Name & Phone Number
Total Number of Prescriptions:
PATIENT’S NEW PRESCRIPTIONS
Do not ll at this time
Contact by: E-mail Phone
Patient’s E-mail Address
Patient’s Permanent Address
City State Zip Code
Patient’s Date of Birth (mm/dd/yyyy)Patient’s Gender: Male Female Patient’s Phone Number
Patient’s Last Name (if different than card holder’s last name) MIPatient’s First Name
CARD HOLDER INFORMATION
Card Holder’s ID Card Holder’s Date of Birth (mm/dd/yyyy)
New Prescription Order Form
Card Holder’s First NameCard Holder’s Last Name MI
DRUG ALLERGIES HEALTH CONDITIONS
Other
None Codeine Sulfa
Aspirin
Arthritis Diabetes Glaucoma High cholesterol
Asthma Depression Heart condition Hypertension
Other
Erythromycin Penicillin
CONTINUED ON BACK
Drug Name
Mail the original physician-signed prescriptions with this completed form. For multiple dependents please use multiple
forms. If more than 3 prescriptions are needed, write the requested information from this table on a separate piece of paper
and enclose with your order. Additional processing time may be required for prescriptions that require physician clarication.
For prescriptions to be lled at a later date, call the customer service number above to activate.
DRAFT
Mail this form to:
PrimeMail
®
PO Box 660319
Dallas, TX 75266-0319
For added service:
Visit www.oridablue.com
or call 888.849.7865
TTY 711
Llame la farmacia de PrimeMail en
888.849.7865 o el registro sobre nuestro
sitio del web en www.oridablue.com
Payment is due with each order and may be made by credit card, check or money order. Orders received without payment
may delay processing. There is a $20 returned check charge.
PAYMENT INFORMATION
Credit card information
To authorize payment by credit card, provide the account number, expiration date and signature. We accept Discover,
MasterCard, VISA and American Express. This card will be used for this and all future orders unless we are notied
otherwise.
Expiration Date
Credit Card Number
DateSignature
Use credit card on le, with the last 4 digits of:
SHIPPING INFORMATION
This is a change of address This is a one time address Seasonal address from to
Alternate Shipping Address (if different than permanent address)
Zip Code Phone NumberCity State
Shipping time does not include processing time. Shipping prices are subject to change.
We are unable to ship second business day or next business day orders to PO boxes.
Shipping address must be a physical location.
Regular: No charge Second business day: $15*
*Additional costs
charged to you.
Next business day: $22*
Check Money Order
Check or money order
Please make check or money order payable to Prime Therapeutics and
include your member ID on the memo line. Do not send cash.
3208
Pharmacy law may permit pharmacists to substitute a less expensive FDA-approved generically equivalent medication
for a brand-name medication unless you or your prescriber indicate otherwise. Some health plans require the patient to
pay the difference between generic and brand name cost.
By returning this form to PrimeMail, you consent to the release and use of the patient’s health information to the
patient’s health plans and health care providers/agents for health benets management. Prime Therapeutics’ use or
disclosure of individually identiable health information, whether furnished by you or obtained from other sources such
as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability
and Accountability Act of 1996).
PrimeMail may contact your physician for clarication and safety purposes, which may result in your physician
prescribing a different, clinically appropriate product.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross
and Blue Shield Association.
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross
and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
PrimeMail is a registered trademark of Prime Therapeutics LLC.
FL NEW
© Prime Therapeutics LLC 04/12
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Completed 9 February 2020

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