Pageflex Mpower Server [ Mail Order Form
User Manual: MailOrderForm
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*6101* Medco By Mail ORDER FORM 1 Member information: Please verify or provide member information below. c Please send me e-mail notices about the status of the enclosed prescription(s) and online ordering at: _________________________@_______________________.______ Member ID: Group: GHIP3RX New shipping address: FOLD HERE Name: Street Address: Street Address: Street Address: City, ST, ZIP: (Medco will keep this address on file for all orders from this membership until another shipping address is provided by any person in this membership.) Daytime phone: 2 Evening phone: Patient/doctor information: Complete one section for each person with a prescription. If a person has prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on back). Send all prescriptions in the envelope provided. First name Last name Birth date (MM/DD/YYYY) Sex M Patient’s relationship to member Self Spouse Dependent F 1st initial Doctor’s last name First name Last name Birth date (MM/DD/YYYY) Sex M Patient’s relationship to member Self Spouse Dependent F 1st initial FOLD HERE Doctor’s last name 3 Doctor’s phone number Doctor’s phone number Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and money orders payable to Medco Health Solutions, Inc., and write your member ID number on the front. You can enroll for e-check payments and price medications at www.medco.com, or call 1 877 204-8150. Number of prescriptions sent with this order: Payment options: e-check For credit card payments: Visa MC Discover Payment enclosed Amex Diners Credit card Send bill Credit card number Expiration date M M Y Y FORM # HH55232M GHI commercial X Cardholder signature I authorize Medco to charge this card for all orders from any person in this membership. Mailing instructions are provided on the back of this form. Patient/doctor information continued First name Birth date (MM/DD/YYYY) Last name Sex M F Patient’s relationship to member Self Spouse Dependent 1st initial Doctor’s last name FOLD HERE First name Birth date (MM/DD/YYYY) Doctor’s phone number Last name Sex M F Patient’s relationship to member Self Spouse Dependent Doctor’s last name 1st initial Doctor’s phone number Important reminders and other information Automatic generic equivalent substitution of certain brand-name drugs is allowed by law in Texas, Florida, and Ohio, unless you or your doctor specifically directs otherwise. c If you live in Texas, you have a right to refuse safe, effective generics. Check the box if you do not want the less expensive, generic drug. This applies only to the prescription drug(s) on this order. c Pennsylvania law permits pharmacists to substitute a less expensive generically equivalent drug for a brand name drug unless you or your physician direct otherwise. Check the box if you do not wish a less expensive brand or generic drug “product.” Please note that this applies only to new prescriptions and to any future refills of that prescription. For additional information or help, visit us at www.medco.com or call Member Services at 1 877 204-8150. TTY/TDD users should call 1 800 759-1089. FOLD HERE Check that your doctor has prescribed the maximum days’ supply allowed by your plan, plus refills for up to 1 year, if appropriate (not a 30-day supply plus refills). Also, ask your doctor or pharmacist about safe, effective, and less expensive generic drugs. Complete the Health, Allergy & Medication Questionnaire. There may be a limit to the balance that you can carry on your account. If this order takes you over the limit, you must include payment. Avoid delays in processing by using e-checks or a credit card. (See Section 3 for details.) If you are a Medicare Part B beneficiary AND have private health insurance, check your prescription drug benefit materials to determine the best way to get Medicare Part B drugs and supplies. Or, call Member Services at 1 877 204-8150. To verify Medicare Part B prescription coverage, call Medicare at 1 800 MEDICARE (1 800 633-4227). Place your prescription(s), this form, and your payment in the envelope provided. Be sure the Medco address shows through the window. Do not use staples or paper clips. MEDCO HEALTH SOLUTIONS OF FAIRFIELD PO BOX 6500 CINCINNATI OH 45273-8152 /4527381523/
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