Prescription Order Form

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Instructions for Placing Your Order
To Mail This Order:
1. Complete or verify the Patient Information section of the order form.
2. Obtain a written prescription from your doctor. Make sure your doctor writes the
prescription for up to a 90-day supply of your medication (or for the maximum days
supply allowed by your benefit). The prescription should include refills for up to one year,
if appropriate.
3. Write the patient's name, ID number, address and date of birth on the prescription.
4. Mail the order form and written prescription to the address below:
Express Scripts, Inc.
P.O. Box 967
BenSalem, PA 19020-0967
To Have Your Doctor Fax This Order:
If you do not have a written prescription in hand, you can bring this order form to your doctor.
Your doctor can then fax both your new prescription and your order.
Please note that your order must be faxed from your doctor’s office. Faxes sent from other
locations (such as your home or workplace) cannot be accepted.
To have your doctor fax your order:
1. Complete or verify the Patient Information section of the order form.
2. Ask your doctor to fax both your new prescription and your order to:
Express Scripts, Inc.
1-800-636-9494
Note: We cannot accept prescriptions for Schedule II controlled substances by fax. All
prescriptions for these medications must be mailed.
Ordering Refills Is Quick and Easy
Return to in two months to order your refill.

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