Scribd
Upload
116 views2 pages

Caremark Mail Order Form

This document is a mail order form for prescription medications. It contains fields for the customer's contact and shipping information, insurance information, doctor and prescription details for up to two people, payment details including credit card or check, and delivery speed options. Customers can use this form to order new prescriptions by mailing it to the provided address along with their prescriptions, or to order refills by writing their prescription numbers in the refill fields.

Uploaded by

aghorbanzadeh
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
116 views2 pages

Caremark Mail Order Form

This document is a mail order form for prescription medications. It contains fields for the customer's contact and shipping information, insurance information, doctor and prescription details for up to two people, payment details including credit card or check, and delivery speed options. Customers can use this form to order new prescriptions by mailing it to the provided address along with their prescriptions, or to order refills by writing their prescription numbers in the refill fields.

Uploaded by

aghorbanzadeh
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

MAIL SERVICE ORDER FORM

Mail order form to: Please fold here Please fold here Please fold here

CVS CAREMARK PGH WB STD PO BOX 2110 PITTSBURGH, PA 15230-2110

Enter ID# if not shown or different from above

Prescription Plan Sponsor or Company Name DIRECTIONS: Print in BLUE or BLACK ink, using CAPITAL letters. Fill in ovals completely ( ). Complete both sides of form. To order new prescriptions: Mail your prescription(s) with this form. # of new prescriptions: To order refills: Order by Web, phone, or write in Rx number(s) below. # of refill prescriptions: FOR FASTEST SERVICE, order refills at www.caremark.com or call the number on your prescription benefit identification card. SHIPPING ADDRESS IF NOT SHOWN OR DIFFERENT FROM ABOVE: Please fold here Last Name Street Address City Daytime Phone #: REFILL INFORMATION: First Name Apt./Suite# State Evening Phone #: MI Suffix (JR, SR)

Use this address for this order only. ZIP Code -

To order mail service refills, enter your prescription number(s) here:

* WEB *

* WEB *

1) 5)

2) 6)

3) 7)

4) 8)

Prescriptions sent in one envelope may be shipped together unless you request otherwise.

2008 Caremark. All rights reserved. P12-N

FILL IN FOR UP TO TWO PEOPLE WHO WILL RECEIVE PRESCRIPTIONS WITH THIS ORDER 1st PERSON ORDERING A PRESCRIPTION
Last Name First Name

Easy open caps Date of Birth:


MM-DD-YYYY

Print in Spanish MI Suffix (JR,SR)

N I C K N AM E Your E-mail: Please fold here

Gender:

Date new prescription written: Please fold here Please fold here

Doctors Last Name Doctors First Name Doctors Phone # ALLERGY/HEALTH INFORMATION: COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED Allergies: None Erythromycin Codeine Aspirin Cephalosporin Peanuts Penicillin Other: Sulfa Conditions: Heart Problem Arthritis Acid Reflux Asthma Diabetes Glaucoma High Blood Pressure Migraine Osteoporosis Prostate Issues High Cholesterol Thyroid Other: 2nd PERSON ORDERING A PRESCRIPTION
Last Name First Name

Easy open caps Date of Birth:


MM-DD-YYYY

Print in Spanish MI Suffix (JR,SR)

N I C K N AM E Your E-mail:

Gender:

Date new prescription written:

Please fold here

Doctors Last Name Doctors First Name Doctors Phone # ALLERGY/HEALTH INFORMATION: COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED Allergies: None Erythromycin Codeine Aspirin Cephalosporin Peanuts Penicillin Other: Sulfa Conditions: Heart Problem Arthritis Acid Reflux Asthma Diabetes Glaucoma High Blood Pressure Migraine Osteoporosis Prostate Issues High Cholesterol Thyroid Other: Special Instructions: PAYMENT INFORMATION: Select one payment method below. Electronic Check Processing (Please pre-register at Caremark.com or call Customer Care)
Bill Me Later (Subject to credit approval. Please pre-register at Caremark.com or call Customer Care)

* WEB *

Credit/Debit Card (VISA, MasterCard, Discover or American Express) Charge most recently used credit card Charge new/updated credit/debit card (provide info below)
Exp. Date
MMDD

. Make check or money order payable to CVS Caremark and write your ID# on the check/money order. Returned checks will be subject to a fee of up to $40, depending on state law. The selected payment method (unless paying by check) will be charged for future orders, unless a different form of payment is provided. It will also be charged for any outstanding balance due. Fill in oval if you DO NOT want the selected payment method to be automatically charged for future orders.
PGH-WB-MOF-1208

Check/Money Order: Amount $

Credit Card Holder Signature/Date REGULAR DELIVERY IS FREE (Allow up to 10 days for delivery) Fill in oval for faster delivery: 2nd Business Day $17 per order Next Business Day $23 per order (Charges subject to change) Faster delivery options only affect shipping time, not processing time and can only be sent to a street address, not a P.O. box.

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy