Web Prescription Order Form - Express Scripts

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WEB PRESCRIPTION ORDER FORM
To FAX your prescription:
To MAIL your prescription:
1. Both “Dr/Prescriber” and “Rx Form” boxes must be filled
1. “Patient” box must be filled out.
out.
2. Have your Doctor write a prescription.
2. Doctor can fax to: 1-866-272-8856
3. Send your new prescription along with this completed
Class II prescriptions cannot be faxed.
form to:
Faxed prescriptions can only be processed if
Express Scripts Home Delivery Service
submitted by a Doctor.
PO Box 66558
Stamped signatures cannot be accepted.
St. Louis MO 63166-6558
PATIENT
DOCTOR/PRESCRIBER
Member ID: ___________________________________
DEA: _________________________________________
First Name:
Last Name:
Name: ________________________________________
_____________________
_______________________
Address: _____________________________________
Date of Birth:
Phone:
_____________________________________________
_____________________
_______________________
Phone: _______________________________________
Address: ______________________________________
Fax: _________________________________________
______________________________________________
PATIENT OPTIONS
______________________________________________
I want non-child resistant caps for all future orders.
E-mail: _______________________________________
I want a copy of my bottle label in large print on a
separate sheet of paper.
Allergies: ______________________________________
Check here for rush shipment. Your order, once
______________________________________________
received and filled, will be shipped overnight for $21.
Health Conditions: ______________________________
______________________________________________
______________________________________________
Over-the-Counter Medications: ____________________
______________________________________________
RX FORM
__ __ / __ __ / __ __
Date:
Last Name
First Name
Refills
Drug Name/Form
Strength
Qty
Directions for Use
X _______________________________________
X
Doctor/Prescriber Signature – Substitution Permissible
Doctor/Prescriber Signature – Dispense as Written
Important Confidentiality Notice: This and any documents accompanying this transmission may contain confidential health information that is legally privileged. This information is intended
only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so
by law or regulation. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents
is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
Express Scripts, Inc.
WLD,E,F,H BLANK WEB FAX FRM Rev 05/12/2010

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