Va Form 10-0426 - Department Of Veterans Affairs Meds By Mail Order Form

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Meds by Mail Order Form
Department of Veterans Affairs
A mail order prescription service for qualified CHAMPVA and Spina Bifida beneficiaries
This form is for Prescription Orders Only
Important Information:
This form is to be completed by the patient, family member, or caregiver with power of attorney. It is
NOT intended to be completed by the medical provider.
Fill out the form completelyyour Social Security number is very important. Meds by Mail may
need to contact you for further medical information.
An order form is required EVERY TIME a written prescription from your medical provider is mailed to
Meds by Mail―even if you have received the same medication from us in the past.
Use a SEPARATE FORM for each patient or family member (up to 15 prescriptions can be ordered
on each form).
Attach the original prescription to this form. Photocopies of prescriptions are not accepted.
Your medication delivery may take up to 21 days from the date you mail your order. Make sure that
you have enough medication on hand to last until your shipment arrives. You may need to
request a second written prescription from your medical provider for a 30 day supply that can be filled
at your local pharmacy to meet your immediate needs until the mail order arrives.
This mail order service is provided only for MAINTENANCE MEDICATION―that is, medications that
are required for extended periods of time. All short-term or one-time-use prescriptions must be
obtained at the local pharmacy of your choice.
How to Request Prescription REFILLS:
This order form is for use when you send hard-copy or written prescriptions from your medical provider
(regardless of whether you have taken the medication in the past). Refill orders are placed using the
REFILL SLIP that accompanies each shipment of medication. To ensure timely delivery, please return
your refill slip as soon as you receive your prescription order. Shipment of medications may take up to 21
days, so DO NOT DELAY in requesting your refills. Read the refill slip carefully, it contains information
you will need concerning the number of refills remaining and the prescription expiration date.
Where to Mail your Prescriptions:
If you live in one of the following states or
If you live in one of the following districts, states or
territories, mail your order form to the address
territories, mail your order form to the address
listed below:
listed below:
Alaska, American Samoa, Arizona, Arkansas,
Alabama, Connecticut, Delaware, Florida,
California, Colorado, Hawaii, Idaho, Illinois,
Georgia, Guam, Kentucky, Maine, Maryland,
Indiana, Iowa, Kansas, Louisiana, Michigan,
Massachusetts, Mississippi, New Hampshire,
Minnesota, Missouri, Montana, Nebraska, Nevada,
New Jersey, New York, North Carolina, Ohio,
New Mexico, North Dakota, Oklahoma, Oregon,
Pennsylvania, Puerto Rico, Rhode Island, South
South Dakota, Texas, Utah, Washington,
Carolina, Tennessee, Vermont, Virginia, Virgin
Wisconsin, Wyoming.
Islands, Washington D.C., West Virginia.
Telephone: 1-888-385-0235
Telephone: 1-866-229-7389
Meds by Mail
Meds by Mail
PO Box 20330
PO Box 9000
Cheyenne, WY 82003-7008
Dublin, GA 31040-9000
Page 1 of 2
AUG 2008


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