Over-The-Counter Health & Wellness Products - Catalog And Order Form - 2015 Page 3
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11OTC Health and Wellness Product Order Form
STEP 1 - Complete your information below
Member ID (from your Humana ID card)
Date of birth
Gender
-
Male
M M
/
D D
/
Y Y Y Y
Female
First name
Last name
nd
2
page of Order Form
Street number and name
Apt/Suite #
City
State
ZIP code
-
Daytime phone
Evening phone
Check box
-
-
-
-
if this is a
new address
STEP 2 – Complete product selection
During which month would you like to receive this order?*
M M
Coversheet
* Please note: Orders can only be placed for the current or a future month. RightSource
is not able to
®
backdate an order for a previous month.
Product code
Product name
Quantity
Price
1 OTC
_______________________________________________
______
2 OTC
_______________________________________________
______
3 OTC
_______________________________________________
______
4 OTC
_______________________________________________
______
5 OTC
_______________________________________________
______
6 OTC
_______________________________________________
______
7 OTC
_______________________________________________
______
Y0040_GNHHXUFEN
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