New Prescription Mail-In Order Form - United Healthcare
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1New Prescription Mail-In Order Form
1
Please use black or blue ink and mail this completed order form with your new prescription(s).
DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.
Primary Member ID Number:
(Additional coverage, if applicable)
Secondary Member ID Number:
Last Name
First Name
MI
Delivery Address
Apt. #
City
State
ZIP
Phone Number with Area Code
Date of Birth (mm/dd/yyyy)
Gender
Email
M
F
Physician Name
Physician Phone Number with Area Code
2
Health history
Medication Allergies:
Health Conditions:
None Known
None Known
Amoxil/Ampicillin
Erythromycin
Sulfa
Arthritis
Glaucoma
Osteoporosis
Tetracyclines
Aspirin
NSAIDs
Asthma
Heart Condition
Thyroid Disease
Cephalosporins
Penicillin
Others:
Cancer
High Blood Pressure
Others:
Codeine
Quinolones
Diabetes
High Cholesterol
Over-the-counter/Herbal medications taken regularly:
3
Pharmacy processing
Generic substitution. FDA-approved generic equivalents will be dispensed for brand-name drugs whenever possible,
unless you or your physician indicate otherwise. Brand-name medications may be subject to a higher cost.
If you require brand-name medications, please list those medications here:
Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date,
please list them here:
Notes to Pharmacy:
4
Payment and shipping information — do not send cash.
Standard delivery is included at no charge. Most prescription orders arrive about 7 days from the date your completed order is
received. If clarification of your order is required, delivery may take longer. If you would like overnight shipping, please indicate
below. Please note that expedited shipping only affects shipping time, not the processing time of your order.
You may log on to to see if drug pricing information is available before enclosing payment.
Once shipped, medications may not be returned for a refund or adjustment.
Ship overnight. Add $12.50 to order amount (subject to change).
Check enclosed. All checks must be signed and made payable to: OptumRx.
Charge to my credit card on file.
Charge to my NEW credit card.
New Credit Card Number
Expiration Date (Month/Year)
/
Visa, MasterCard, AMEX and Discover are accepted.
Signature:
Date:
For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance, and other such expenses
related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file
as payment method for any future charges. To modify payment selection, Customer Service can be contacted at any time.
UHCEX610450_001 12/12
OptumRx, P.O. Box 2975, Mission, KS 66201
ORX5633-UHCEIW_121205
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Parent category: Medical