Mail Service Order Form - Caremark
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1
2or information, visit our Web
site at
or call the number on your
prescription card.
Mail Service Order Form
Instructions:
Please PRINT in CAPITAL letters using BLACK ink only. Fill in the applicable ovals completely ( ).
Mail this completed form, the doctor’s signed prescription(s), and your payment to
15749
Caremark in the envelope provided or to the address on the bottom of this form.
Rev. 02/07
Plan Participant Information/
1
Health History
Primary Plan Participant Identification Number (refertoyourprescriptioncard)
Date Form Submitted:
Primary Plan Participant Name (LastName)
(FirstName)
(MI)
Delivery Address (ifyouselect2ndDayorNextDayshipping,fillinastreetaddress,notaP.O.Box)
City
State
Zip
Phone Number
(
)
Above delivery address is:
Forthisorderonly
Forthisandallfutureorders
E-mail Address, if available
This information will not be shared with any outside party. If other household members also use this e-mail address, they may be
able to access your health information.
Mark all allergies or conditions that apply to you, your spouse or covered dependents that have
a prescription submitted with this form by completely filling in the oval below that description.
Contact your doctor if you are unsure about any health conditions. This information will not be
required on future order forms unless there has been a change in health status.
Birthdate
Primary Plan Participant’ s First Name
M M
D
D
Y
Y
Y
Y
Spouse’ s First Name
Other Dependent’ s First Name
Other Dependent’ s First Name
Please write first name and then list “other allergies”and/or “other conditions”referenced above
Listanynon-prescriptionmedicinesthatyoutakeonaregularbasisorprescriptionmedicinesthatyouobtainwithoutyourCaremark
prescription plan:
Caremark
•
P.O. Box 3223
•
Wilkes-Barre, PA 18773-3223
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