Fillable maxor pharmacy mail order form

Fill Online, Printable, Fillable, Blank maxor pharmacy mail order form Form

Use Fill to complete blank online MOHAWK VALLEY COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

maxor pharmacy mail order form

On average this form takes 15 minutes to complete

The maxor pharmacy mail order form form is 2 pages long and contains:

  • 0 signatures
  • 29 check-boxes
  • 48 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Mohawk Valley Community College

BROWSE MOHAWK VALLEY COMMUNITY COLLEGE 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
 
3
GENERIC MEDICATION INFORMATION
MAIL ORDER FORM
Mail your order to:
PO Box 32050
Amarillo, TX 79120
1
PATIENT INFORMATION
2
DRUG ALLERGIES & CHRONIC ILLNESSES
4
PAYMENT METHOD
E-mail Address:
None Codeine Sulfa Aspirin Penicillin Other
Drug Allergies:
Mild Moderate Severe Intolerance Anaphylaxis
Severity of Drug Allergies:
Other
Glaucomayroid
Heart Condition
High Blood Pressure
Intestinal Disorders
Diabetes
Lung Condition
Chronic Illnesses:
(Disease States)
Check/Money Order Credit Card
Payment Options:
Maxor will keep this address on file for all orders filled
on this account until another address is provided.
For address changes, please call
For address changes, please call
Maxor Mail Order at (800) 687-8629.
Maxor Mail Order at (800) 687-8629.
Phone:
D.O.B.:
Check here to decline keeping credit card information on file
at the pharmacy.
Self Spouse Child
Relationship to Cardholder:
Credit Card Number:
1
Please refer to the reverse side of this form for further details.
In order to process your prescriptions quickly, please enclose the correct co-payment amount(s). If assistance is
needed with calculating co-payment amount(s), please call MaxorPlus at (800) 687-0707.
Paying By Credit Card?
Visa MasterCard Discover American Express
Expiration Date:
MM/YYYY
X
Signature of Cardholder
Note: Expedited shipping will not
not
rush prescription processing. Prices subject to change.
$25.00 for overnight shipping
Expedited Shipping via UPS or FedEx:
$15.00 for 2-day shipping
Call Us Toll Free At
(800) 687-8629
or (806) 324-5500
Monday-Friday – 7:00 am to 9:00 pm CST • Saturday − 8:00 am to 6:00 pm CST • Sunday – 9:00 am to 5:00 pm CST
Use reverse side for prescription refills.
Credit card already on file.
In accordance with Texas Pharmacy Law and availability Maxor Pharmacy will always dispense a generic medication with a lower co-payment unless
you specify otherwise. Please contact a customer care associate at (800) 687-8629 to advise us of medications that you want dispensed brand-name
only or use the space provided on the reverse side of this form to notify us of brand-name only medication exceptions.
Cardholder ID:
Group ID:
Name:
Street Address:
City: State: Zip:
Male Female
Sex:
6
HOW TO ORDER
7
IMPORTANT IMFORMATION
5
ORDER REFILLS
For address changes, please call
Maxor Mail Order at (800) 687-8629.
not
e submission of this form, for you or any of your dependents, authorizes the release of all information to the Plan Sponsor, Administrator, or
Underwriter, and authorizes the prescription to be filled with the generic equivalent when available and permissable by law, in accordance with
your benefit plan requirements. If you request a brand name drug when your doctor permits substitution, you may be responsible for paying the
difference in cost between the brand name drug and the generic equivalent plus a co-payment. Refer to your plan benefit information for more
details or contact a customer care associate at (800) 687-8629.
Reminder: You will always be charged the mail order co-pay when you send or transfer a prescription to Maxor Mail Order.
To maximize your savings, ask your doctor for a 90 day supply with refills up to one year.
Written information about this prescription has been provided for you.
Please read this information before you take this medication. If you have
questions concerning this prescription, a pharmacist is available during
normal business hours to answer your questions. Please call your
pharmacy.
Complaints against the practice of
pharmacy may be filed with the:
Texas State Board of Pharmacy
William P. Hobby Building, Suite 3-600
333 Guadalupe, Box 21
Austin, Texas 78701-3942 • (512) 305-8000
To receive a complaint form call
(800) 821-3205 or (512) 305-8080 if in Austin.
(recorded information only)
www.tsbp.state.tx.us
Se la presentado a usted la informacion por escrito sobre esta receta.
Favor de leer esta informacion antes do tomar el medicamento. Si usted
tiene preguntas tocante a esta receta, estara un farmaceutico disponible
durante las horas de negocio para contestar sus preguntas. Por favor
llame a su pharmacia.
Quejas contra la practica de la
farmacia pueden ser reportadas al:
Concilio de Farmacia Del Estado De Tejas
William P. Hobby Building, Suite 3-600
333 Guadalupe, Box 21
Austin, Texas 78701-3942 • (512) 305-8000
Para recibir una forma de queja llame:
(800) 821-3205 or (512) 305-8080 if in Austin.
(informacion grabada solamente)
www.tsbp.state.tx.us
Questions? Call Maxor Pharmacy toll-free at (800) 687-8629,
Monday-Friday – 7:00 am to 9:00 pm CST • Saturday − 8:00 am to 6:00 pm CST • Sunday – 9:00 am to 5:00 pm CST
BY MAIL: Complete the payment and refill sections, and mail to Maxor Mail Order.
BY PHONE: Call toll free (800) 687-8629 or (806) 324-5500 and use our automated system to enter the Rx number printed on your
prescription label, or speak to a customer service representative during normal business hours.
BY INTERNET: You may refill your prescriptions on our website at www.maxor.com. Please choose the REFILL PRESCRIPTIONS
section under FILLING YOUR PRESCRIPTIONS. You will need your prescription numbers and credit card information available.
HOW TO ORDER REFILLS
is form is used to order refills or new prescriptions. Please mail this form 14 days in advance
before your medication runs out and enclose the appropriate co-payment amount.
1
Brand-Name Only Medication Exceptions:
Rx Number Name of Medication Strength Doctor’s Name Co-payment
Rx Number Name of Medication Strength Doctor’s Name
Co-payment
Order Refill Prescriptions Here:
BY MAIL: Complete the payment and patient information sections, enclose your new prescriptions, and mail to Maxor Mail Order.
BY PHONE: Have your doctor call in new prescriptions to (800) 687-8629 or (806) 324-5500.
BY FAX: Your doctor can fax new prescriptions to (866) 589-7656. In accordance with Texas law, only your doctor can fax new prescriptions.
HOW TO ORDER NEW PRESCRIPTIONS
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

maxor pharmacy mail order form

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 17 December 2019

Message

View Audit Log
Print With Audit Log
Duplicate Document