Aetna Rx Home Delivery Form Page 2
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Tell us about the people ordering prescriptions. If there are more than two people, please complete another form.
First person with a refill or new prescription.
Spanish forms and labels
Last Name
First Name
MI
Suffix
(JR,SR)
Nickname
Date of Birth:
Gender:
M
F
MM-DD-YYYY
E-Mail Address:
Date new prescription written:
Doctor’s Last Name
Doctor’s First Name
Doctor’s Phone #
Tell us about new health information for 1st person if never provided or if changed.
Allergies:
None
Aspirin
Cephalosporin
Codeine
Erythromycin
Peanuts
Penicillin
Sulfa
Other:
Medical Conditions:
Arthritis
Asthma
Diabetes
Acid Reflux
Glaucoma
Heart Problem
High Blood Pressure
High Cholesterol
Migraine
Osteoporosis
Prostate Issues
Thyroid
Other:
Second person with a refill or new prescription.
Spanish forms and labels
MI
Last Name
First Name
Suffix
(JR,SR)
Nickname
Date of Birth:
Gender:
M
F
MM-DD-YYYY
E-Mail Address:
Date new prescription written:
Doctor’s Last Name
Doctor’s First Name
Doctor’s Phone #
Tell us about new health information for 2nd person if never provided or if changed.
Allergies:
None
Aspirin
Cephalosporin
Codeine
Erythromycin
Peanuts
Penicillin
Sulfa
Other:
Medical Conditions:
Arthritis
Asthma
Diabetes
Acid Reflux
Glaucoma
Heart Problem
High Blood Pressure
High Cholesterol
Migraine
Osteoporosis
Prostate Issues
Thyroid
Other:
D
Special Instructions:
E
How would you like to pay for this order? (If your copay is $0, you do not need to provide payment information.)
Electronic Check. Pay from your bank account. (You must first register online or call Customer Care.)
Use my PayPal Credit account. Works like a credit card. (You must first register online.)
Credit or Debit Card. (VISA
, MasterCard
, Discover
, or American Express
)
®
®
®
®
Use your card on file.
Use a new card or update your card’s expiration date.
Exp.Date
MMYY
Credit Card Holder Signature/Date
Check or Money Order. Amount: $
.
Regular delivery is free and will take 10 to 14
• Make check or money order out to Aetna Rx Home Delivery.
days from the day you send this form.
• Write your Aetna Member ID number on your check or
If you want faster delivery, choose:
money order.
2nd Business Day ($17)
Business days
• If your check is returned, we will charge you up to $40.
are only
Next Business Day ($23)
Monday-Friday
Payment for balance due and future orders: If you choose
•
Faster delivery charges may change.
Electronic Check, PayPal Credit, or a Credit Card or Debit Card,
•
Faster delivery is for shipping time, not processing time.
we will also use it to pay for any balance that you owe and for
•
Faster delivery can only be sent to a street address,
future orders unless you provide another form of payment.
not a PO box.
Fill in this oval if you DO NOT want to use this payment
method for future orders.
I authorize Aetna Rx Home Delivery to bill my credit card for any out-of-pocket
costs or special shipping costs in effect at the time my order is filled.
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Parent category: Business