Va Form 10-0426 - Meds By Mail Prescription Order Form
Download a blank fillable Va Form 10-0426 - Meds By Mail Prescription Order Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 10-0426 - Meds By Mail Prescription Order Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
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.
● 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.
● This order form is required EVERY TIME a written prescription from your medical provider is mailed.
● 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. To ensure that
you have enough medication to last until your shipment arrives, you may need to request a second
written prescription 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 short-term or one-time-use prescriptions must be obtained
at your local pharmacy.
How to Request Prescription REFILLS:
This form is for use when you send a paper prescription written by your medical provider. Refill orders
should be placed by calling our automated refill system. Simply call 1-888-370-1699 and follow the voice
prompts. Refill orders may also be placed using the refill slip that accompanies each shipment of
medication. If you choose to reorder by mail, be sure to return your refill slip as soon as you receive your
prescription order, as it may take up to 21 days to process your order. 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:
WEST
EAST
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
Address:
Address:
Meds by Mail
Meds by Mail
PO Box 20330
PO Box 9000
Cheyenne, WY 82003-7008
Dublin, GA 31040-9000
VA FORM
10-0426
Page 1 of 2
AUG 2010
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal