Walgreens Mail Order Form
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2*17300000000REG001*
INTERCOM: Please provide the RxBIN and
RxPCN numbers from your ID Card
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M
S
P
T
AIL
ERVICE
HARMACY
IPS
RxBIN:
MAIL REGISTRATION & PRESCRIPTION ORDER FORM
• New prescriptions must be mailed to Walgreens
RxPCN:
Plan Name
(if on ID card)
Mail Service pharmacy. Please select a location of
Suffix extension
Patient needs Spanish vial labels
MEMBER INFO.
your choice from the labels provided.
Male
Female
if on ID card
Patient needs snap-on caps
• For long-term medications you need right away:
ID Number (Important-
ask your doctor for two prescriptions–one for
copy from ID card)
a small supply to fill at a participating retail
Name (First, Last)
Date of Birth (MM/DD/YYYY)
pharmacy and one for a long-term supply to
/
/
fill through the mail.
Shipping Address (Please do not use P.O. Box)
Daytime Phone
• Most orders are shipped by U.S. Postal Service.
(
)
Controlled substances may require an adult
City
State
ZIP Code
Evening Phone
signature upon receipt. Packaging does not show
(
)
any indication that medications are enclosed.
E-mail Address
Dr. Name
Dr. Phone (Required)
• Allow 2 weeks for delivery.
(
)
• Emergency prescriptions can be shipped overnight.
Please call our Customer Care Center.
ALLERGIES:
No Known
32-Codeine
70-Penicillin
87-Sulfa
93-Tetracycline
Other (list):
• Include payment, if applicable to avoid any delays.
Please do not send cash.
HEALTH CONDITIONS:
No Known
200-Diabetes
300-Hypertension
400-Heart Disease
500-Glaucoma
600-Stomach disorders
• Make checks payable to Walgreens Mail Service.
700-Thyroid disease
800-Arthritis
Other (list):
Credit cards accepted.
• Refills cannot be transferred from other pharmacies.
PAYMENT
- CHECK OR CREDIT CARD (VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS)
Request a new prescription from your doctor.
It is standard pharmacy practice to substitute
Number
Cost (ea.)
Subtotal
• Use black ink only. Enclose form with
enclosed
generic equivalents for brand-name drugs whenever
prescription(s) and payment.
possible. Walgreens Mail Service will dispense an
$
$
FDA-approved generic equivalent whenever available,
Customer Care Center:
$
$
permitted by your prescriber, and allowable by law. If
1-888-832-5462 (TTY: 1-800-573-1833)
TOTAL AMOUNT ENCLOSED
$
you do not want a generic equivalent, please call our
Monday–Friday 8:00 a.m. - 10:00 p.m. (Eastern)
Please contact your plan sponsor for
Customer Care Center to advise.
benefit questions.
Saturday–Sunday 8:00 a.m. - 5:00 p.m. (Eastern)
Refills by Phone:
Credit Card Number
1-800-RX-REFILL (1-800-797-3345)
Credit Card Expiration
Signature (for credit card)
(en español: 1-800-778-5427)
(MM/YY)
/
Internet:
Please complete both sides of this form.
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