Mail this form to:
Enter ID # below if not shown or if different from above
Number of New prescriptions:
Number of Refill prescriptions:
Please use blue or black ink, capital letters, and fill in both sides of this form.
Shipping Address. To ship to an address different from the one printed above, please make changes here.
New Prescriptions - Mail your new prescriptions with this form.
Refills - Order by Web, phone, or write in Rx number(s) below.
We may package all of these prescriptions together unless you tell us not to.
Refills. To order mail service refills, enter your prescription number(s) here.
A
B
Use this address
for this order only.
Apt./Suite #
City
State ZIP Code
Street Name
-
-
-
-
Daytime Phone #: Evening Phone #:
Last Name
First Name MI Suffix (JR, SR)
1) 2) 3) 4)
5) 6) 7) 8)
Prescription Plan Sponsor or Company Name
©2010 Caremark. All rights reserved. P13-N
Mail Service
Order Form
FOR FASTEST SERVICE, order refills at www.caremark.com or call the number on your
prescription benefit ID Card.
CVS CAREMARK
PO BOX 94467
PALATINE, IL 60094-4467
.
Tell us about the people getting prescriptions. If there are more than two people, please complete another form.
1st person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels
Tell us about new allergies or health information for this person. Only tell us about new information.
Allergies:
Health Information:
Special Instructions:
Electronic Check. Pay from your bank account. First time users register online or call Customer Care.
Bill Me Later
®
. Works like a credit card. First time users register online or call Customer Care.
Credit or Debit Card. (VISA
®
, MasterCard
®
, Discover
®
, or American Express
®
)
Fill in this oval to use your card on file.
Fill in this oval to use a new card or to update your card expiration date.
Check or Money Order. Amount: $
Regular delivery is free
and will take 7 to 10
days from the day you send this form.
• Faster delivery charges may change.
• Faster delivery is for shipping time, not processing time.
• Faster delivery can only be sent to a street address,
not a PO box.
C
D
How would you like to pay for this order? Fill in the oval to choose a payment.
E
2nd person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels
ErythromycinCephalosporin CodeineAspirinNone
Sulfa Other:
Peanuts
Arthritis Asthma Diabetes Acid Reflux Glaucoma
High Blood Pressure
Other:
High Cholesterol Migraine Osteoporosis Prostate Issues
Penicillin
Heart Problem
Thyroid
Gender: M F Date of Birth:
Date new prescription written:
Doctor’s Last Name Doctor’s First Name Doctor’s Phone #
Tell us about new allergies or health information for this person. Only tell us about new information.
Allergies:
Health Information:
ErythromycinCephalosporin CodeineAspirinNone
Sulfa Other:
Peanuts
Arthritis Asthma Diabetes Acid Reflux Glaucoma
High Blood Pressure
Other:
High Cholesterol Migraine Osteoporosis Prostate Issues
Penicillin
Heart Problem
Thyroid
Gender: M F Date of Birth:
Your E-Mail:
Your E-Mail:
Date new prescription written:
Doctor’s Last Name Doctor’s First Name Doctor’s Phone #
Fill in this oval if you DO NOT want to use this payment
method for future orders.
2nd Business Day ($17)
Next Business Day ($23)
If you want faster delivery, choose:
Credit Card Holder Signature/Date
Exp.
Date
Suffix
(JR,SR)
Suffix
(JR,SR)
Business days
are only
Monday-Friday
MTP-MOF-2010
• MakecheckormoneyorderouttoCVSCaremark.
• WriteyourprescriptionbenetIDnumberonyour
check or money order.
• Ifyourcheckisreturned,wewillchargeyouupto$40.
Payment for Balance Due and Future Orders: If you chose
Electronic Check, Bill Me Later
®
, or a Credit or Debit Card,
we will also use it to pay for any balance that you owe and
for future orders.
