Form Hb42972m - Medco By Mail Order Form
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1
2Medco By Mail Order Form
Benefits provided by Physicians Health Plans
For New Prescriptions
To order by mail: Include your refill slip(s) with this form. Do not
Fill out one line of the Patient Information section for each new
complete the Patient Information section for refills.
prescription you send. Be sure to include the patient's full name,
For All Mail Orders
date of birth, and address, along with the doctor's name and
Place all prescriptions and refill slips together with this completed
phone number. Please remember to provide your member ID.
order form and your co-payment in the enclosed return envelope.
For Refills
Be sure to fold the form as indicated so the address on the bottom
right shows through the window.
To order from our website: Have your
member ID number and prescription (Rx) number on hand. Your
If You Need Additional Help
12-digit prescription or Rx number can be found on your refill slip.
Call Member Services at 1-800-654-4216. We are available 24
To order by phone: Call 1-800-4REFILL (1-800-473-3455) to use
hours a day, 7 days a week (except Thanksgiving and Christmas).
the automated refill system. Have your member ID number and
The best time to call is in the afternoon, Tuesday through Friday.
refill slip with the prescription information ready.
See the back of this form for additional instructions.
c Please send me e-mail notices about the status of the enclosed
Member Information
prescription(s) and online ordering at:
--------------
Policy #:
Group: PHPRX
____________________@_______________________________.______
Name:
Street Address:
Street Address:
Street Address:
Shipping address if different from your mailing address
City, ST, ZIP:
Temporary
Permanent
Check if
Daytime telephone
Evening telephone
Patient Information–
Complete one line for each new prescription (Do not complete for refills)
Does patient
Patient name
Patient's relation to plan
Birth date
Doctor name
have any other
member (fill in one)
Sex
M/D/YYYY
and phone number
prescription plan?
1
/
/
Yes
Self
Spouse
Dependent
M
F
No
2
/
/
Self
Spouse
Dependent
M
Yes
F
No
3
/
/
Self
Spouse
Dependent
Yes
M
F
No
--------------
Order Information
Paying by credit card?
MC
Disc/NOVUS
AmEx
Visa
Diners
Total number of medications in this order
(including all refills and new medications)
CREDIT CARD NUMBER
M
Y
X
Subtotal of this order
.
EXPIRATION DATE
CARDHOLDER SIGNATURE
Optional expedited shipping
.
Check here to have all orders billed to your credit card.
$14.00 (subject to change)
By doing so, you authorize Medco to keep your card number on file
and bill all future orders and any outstanding balances directly to
Total enclosed
.
your credit card. To enroll by phone, please call 1-800-948-8779.
(do not send cash)
Paying by check? Write your member ID number on your check or
money order made payable to Medco Health Solutions, Inc.
Please be sure address
is visible through window
of envelope marked
"Medco By Mail Order Center."
MEDCO
PO BOX 30493
TAMPA FL 33630-3493
/3363034936/
FORM #
HB42972M
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