By Mail Order Form
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1
2Medco By Mail
Order Form
Benefits Provided by UnitedHealthcare
For Refills
To order from our Web site: Have your Subscriber
date of birth, and address, along with the doctor’s name and
number and Prescription (Rx) number on hand. Your 12-digit
phone number. Be sure your prescription is written for a
Prescription or Rx number can be found on your refill slip.
90-day supply with refills.
For All Mail Orders
To order by phone: Call 1 800 4REFILL (1 800 473-3455) to use the
automated refill system. Have your Subscriber number and your
Place all prescriptions and refill slips together with this
refill slip with the prescription information ready.
completed order form and your co-payment in the enclosed
return envelope.
To order by mail: Include your refill slip(s) with this form. Do not
If You Need Additional Help
complete the Patient Information section for refills.
Call Customer Care at the number on your ID card.
For New Prescriptions
Fill out one line of the Patient Information Section for each new
See the back of this form for additional instructions.
prescription you send. Be sure to include the patient’s full name,
Customer Information
RxGrp:
UHEALTH
Subscriber #: ____________________
Shipping address if different from your mailing address
Check if
Temporary
Permanent
Name: ____________________________________________________________
Street Address: ______________________________________________________
Street Address: ______________________________________________________
City, ST, ZIP: ________________________________________________________
Daytime telephone
Evening telephone
Patient Information
—c
omplete one line for each new prescription (Do not complete for refills)
Does patient
Patient name and Medicare B
Patient’s relation to plan
Birth date
Doctor name
have any other
number (if applicable)
subscriber (fill in one)
Sex
M/D/YYYY
and phone number
prescription plan?
1
Self
Spouse
Dependent
M
/
/
Yes
F
No
2
Self
Spouse
Dependent
M
/
/
Yes
F
No
3
Self
Spouse
Dependent
M
/
/
Yes
F
No
Order Information
Paying by Credit Card?
Visa
MC
Disc/NOVUS
AmEx
Diners
Total number of medications in this order
(including all refills and new medications)
CREDIT CARD NUMBER
X
M
Y
Subtotal of this order
$
.
EXPIRATION DATE
CARDHOLDER SIGNATURE
Optional expedited shipping
.
Check here to have all orders billed to your credit card.
$9.00 per order (subject to change)
By doing so, you authorize Medco to keep your card
Total enclosed
number on file and bill future orders and any outstanding
$
.
(do not send cash)
balances directly to your credit card. To enroll by phone,
please call 1 800 948-8779.
Paying by check? Write your Subscriber number on your check or
You can check your mail order co-payments online at
money order made payable to Medco.
Ask your doctor to write your prescription for a 90-day supply with refills
when appropriate. You will be charged a mail order co-payment regard-
ATTN: XXXXXXXXX
less of the days supply written on the prescription. Please be sure that
MEDCO
your doctor writes your prescription for a 90-day supply, not a
P O BOX 747000
30-day supply with 3 refills.
CINCINNATI OH 45274-7000
100-4213 10/05 HB902497
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