Form 2560il - Bcbs Fax Order Form printable pdf download

Fax Order Form

NOTE: ORDERS NOT FAXED FROM A LICENSED PHYSICIAN’S OFFICE

WILL NOT BE PROCESSED.

DO NOT FAX PRESCRIPTIONS FOR CONTROLLED SUBSTANCES.

Physician: Fax completed form to PrimeMail

Pharmacy at 877.774.6360.

Patient: PrimeMail Pharmacy is your mail service pharmacy. Please make every attempt to obtain

P R E S C R I P T I O N S E C T I O N

a new written prescription from your physician and send it with your Blue Cross order form and

payment to: PrimeMail Pharmacy, P.O. Box 650041, Dallas, TX 75265-0041

R x

For ________________________________________ Date _______________

Follow these steps to obtain your prescription:

Address ___________________________________ Phone _____________

Complete the Member, Patient and Payment Sections below using black ink only. A credit

card number is required at the time the form is submitted.

Ask your doctor to fill out the Prescription Section and fax this form to 877.774.6360.

Please allow 10 to 14 days for delivery from the date your physician faxes in your prescription.

By returning this form to PrimeMail, you consent to the use and release of your health information and that of

your covered dependents (if you are their guardian or authorized representative) to your health plans and

health care providers/agents for health benefits management. Blue Cross and Blue Shield’s use or disclosure

of individually identifiable health information, whether furnished by you or obtained from other sources such

as medical providers, shall be in accordance with the federal privacy regulations under HIPAA (Health

Insurance Portability and Accountability Act of 1996).

M E M B E R S E C T I O N

(MUST COMPLETE EVERY FIELD)

Member ID Number

Member Date of Birth

Group Number

(copy from your ID card)

Member Name

Daytime Phone

Evening Phone

(First, M.I., Last)

Address

Email Address

(please do not use a P.O. box)

City

State

Zip

P AT I E N T S E C T I O N

K Male

Patient Name

Patient Date of Birth

(First, M.I., last if different from member)

K Female

Patient Email Address

PATIENT ALLERGIES

PATIENT CONDITIONS

K None Known

K Sulfa

K None Known

K Heart Condition

K Aspirin

K Tetracycline

K Diabetes

K Hypertension

K Codeine

K Other Allergy

K Epilepsy

K Ulcer

_________

K Penicillin

K Glaucoma

K Other Condition

___________________

_____________

Physician Name

Physician Phone

Dr ________________________________ Dr _________________________________

PrimeMail Pharmacy staff may contact your physician for clarification and safety purposes, which

Dispense as written

Substitution permissible, may substitute

may result in your physician prescribing a different, clinically-appropriate product. PrimeMail

Pharmacy will dispense FDA-approved generic equivalents when available and appropriate.

Physician Name

______________________________________________ _

(Please print)

P A Y M E N T S E C T I O N

Refills ________ Times

Address _____________________________________

Credit Card Number

Expiration Date

(MM/YYYY)

DEA# ___________________ Phone _______________________________________

K American Express

K Discover

Credit Card Holder’s Signature

K MasterCard

K Visa

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

an Independent Licensee of the Blue Cross and Blue Shield Association

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Form 2560il - Bcbs Fax Order Form

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