Member information: Please verify or provide member information below.
(Express Scripts will keep this address on file for all orders fromthis membership until another shipping address is provided by any person in this membership.)
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Patient/doctor information: Complete one section for each person with a prescription. If a person hasprescriptions from more than one doctor, complete a new section for each doctor (additional sections are onback). Send all prescriptions in the envelope provided.
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Mailing instructions are provided on the back of this form.
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Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and money orderspayable to Express Scripts, and write your member ID number on the front. You can enroll for e-check paymentsand price medications at Express-Scripts.com, or call the Member Services phone number found on your ID card.
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First name Last name
Doctors phone numberDoctors last name 1st initial
Patients relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent M F
First name Last name
Doctors phone numberDoctors last name 1st initial
Patients relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent M F
For credit card payments:Visa MC Discover Amex Diners
Payment options: e-check Payment enclosed Credit card Send bill
Number of prescriptions sent with this order:
I authorize Express Scripts to charge this card forall orders from any person in this membership.
Credit card number
Expiration date
M M Y Y Cardholder signatureX
MLRFOHNW
HOME DELIVERYORDER FORM
Evening phone:
Member ID:Group:Name:
Street Address:
Street Address:
Street Address:
City, ST, ZIP:
Daytime phone:
*6101*
Rush the mailing of this shipment ($21, cost subject to change). NOTE: This will only rush the shipping,not the processing of your order. Street address is required; P.O. box is not allowed.
Please send me e-mail notices about the status of the enclosedprescription(s) and online ordering at:
@ .
New shipping address:
Place your prescription(s), this form, and yourpayment in an envelope. Do not use staples or paper clips.
Patient/doctor information continued
Important reminders and other information
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Express Scripts will make all possible efforts, asappropriate by law, to substitute generic formulationsof medication, unless you or your doctor specificallydirects otherwise.
Pennsylvania and Texas laws permit pharmacists tosubstitute a less expensive generic equivalent for a brand-name drug unless you or your doctor directs otherwise.Check the box if you do not wish a less expensivebrand or generic drug.Please note that this applies only to new prescriptions and toany refills of that prescription.For additional information or help, visit us at Express-Scripts.com or call Member Services at the phonenumber found on your ID card. TTY/TDD users should call1.800.759.1089.
Federal law prohibits the return of dispensed controlledsubstances.
Check that your doctor has prescribed the maximum dayssupply allowed by your plan (not a 30-day supply), plusrefills for up to 1 year, if appropriate. Also, ask your doctoror pharmacist about safe, effective, and less expensivegeneric drugs.Complete the Health, Allergy & Medication Questionnaire.There may be a limit to the balance that you can carryon your account. If this order takes you over the limit, youmust include payment. Avoid delays in processing by usinge-checks or a credit card. (See Section 3 for details.)If you are a Medicare Part B beneficiary AND haveprivate health insurance, check your prescription drugbenefit materials to determine the best way to getMedicare Part B drugs and supplies. Or, call MemberServices at the phone number found on your ID card. Toverify Medicare Part B prescription coverage, callMedicare at 1.800.633.4227.
First name Last name
Doctors phone numberDoctors last name 1st initial
Patients relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent M F
First name Last name
Doctors phone numberDoctors last name 1st initial
Patients relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent M F
MLRFOHNW
EXPRESS SCRIPTS
PO BOX 747000
CINCINNATI, OH 45274-7000
C
037338 (07-2016)
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:(Arabic) .
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