Va Form 10-0426 - Meds By Mail Order Form - Department Of Veterans Affairs
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1
2Meds 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 must be filled out completely including your Social Security number and Date of
Birth for identification purposes. If you cannot be identified, your prescription will not be filled.
● Attach the original prescription to this form. Photocopies of prescriptions are not accepted.
● This order form is required EVERY TIME a written prescription from your medical provider is mailed.
● This form is to be completed by the patient, family member, or caregiver with power of attorney.
● Use a separate form for each patient or family member.
● Medication delivery may take up to 21 days from the date you mail your order. To ensure that you
have enough medication to last until your shipment arrives, request a second written prescription for a
30-day supply from your medical provider that can be filled at your local pharmacy.
● This mail order service is provided only for maintenance medication―that is, medications that are
required for extended periods of time. All immediate-use or one-time-use prescriptions and all CII
controlled substance prescriptions must be obtained at your local pharmacy.
Patient Prescription Information
-
This form must be filled out completely
TYPE or PRINT information below:
Patient Name: (Last, First, Middle Initial)
Patient SSN
Date of Birth
(mm-dd-yyyy)
Mailing Information (Type or Print where the prescriptions are to be mailed)
Patient Mailing Address:
Daytime Phone Number (Including Area Code) :
Cell:
Home:
Address 1
Today's Date:
Address 2
NON-SAFETY CAP REQUEST:
City
Federal law requires that your medication be dispensed in a
container with a child resistant or safety cap. If you would like your
State
Zip
prescription with an “Easy-Open” lid, please sign below:
I request that these prescriptions and all refills of these
Is this a change of address?
Yes
No
prescriptions dispensed in “Easy-Open” or NON-child-resistant
Is this a permanent change?
Yes
No
containers.
Is this a temporary change?
Yes
No
Signature:
Medication Allergies
Health Conditions
No known allergies
Arthritis
Glaucoma
Liver Disease
Aspirin
NSAIDS
Asthma
Heart Problem
Seizures/Epilepsy
Cephalosporin
Penicillin
COPD
High Cholesterol T Thyroid
Codeine
Sulfa
Depression
Hypertension
Ulcer/Acid Reflux
Erythromycin
Tetracycline
Diabetes
Kidney Disease
Other (specify)
Other (specify)
Food Allergy (specify)
VA FORM
10-0426
Page 1 of 2
JAN 2016
VA FORM
10-0426
Page 1 of 2
DEC 2016
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