Express Scripts Fax Form printable pdf download

Express Scripts Fax Form

The Medco Pharmacy

is now a part of the Express Scripts family of pharmacies.

Confidentiality notice This communication and any attachments are intended solely for the use of the addressee named above and it contains confidential and

legally privileged information. If you are not the intended recipient any dissemination distribution or copying is strictly prohibited. If you received this communica-

tion in error please notify Express Scripts by fax or phone immediately. The Express Scripts fax system is secure and in compliance with HIPAA privacy standards.

The provision of the information requested in this form is for your patient’s benefit Express Scripts does not compensate for completing this form