Form DODMOFWB "Home Delivery Order Form - Express Scripts"

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Download Form DODMOFWB "Home Delivery Order Form - Express Scripts"

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*6101*
HOME DELIVERY
ORDER FORM
1
Member information: Please verify or provide member information below.
Please send me e-mail notices about the status of the enclosed
Member ID:
prescription(s) and online ordering at:
Group:
@
.
Name:
New shipping address:
Street Address:
Street Address:
Street Address:
(Express Scripts will keep this address on file for all orders from
City, ST, ZIP:
this membership until another shipping address is provided by
any person in this membership.)
Daytime phone:
Evening phone:
2
Patient/doctor information: Complete one section for each person with a prescription. If a person has
prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on
back). Send all prescriptions in the envelope provided.
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
3
Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and money orders
payable to Express Scripts, and write your member ID number on the front. You can enroll for e-check payments
and price medications at Express-Scripts.com, or call the Member Services phone number found on your ID card.
Number of prescriptions sent with this order:
Payment options:
e-check
Payment enclosed
Credit card
Send bill
For credit card payments:
Credit card number
Visa
MC
Discover
Amex
Diners
Expiration date
X
I authorize Express Scripts to charge this card for
all orders from any person in this membership.
M M Y Y
Cardholder signature
Rush the mailing of this shipment ($21, cost subject to change). NOTE: This will only rush the shipping,
not the processing of your order. Street address is required; P.O. box is not allowed.
DODMOFWB
Mailing instructions are provided on the back of this form.
*6101*
HOME DELIVERY
ORDER FORM
1
Member information: Please verify or provide member information below.
Please send me e-mail notices about the status of the enclosed
Member ID:
prescription(s) and online ordering at:
Group:
@
.
Name:
New shipping address:
Street Address:
Street Address:
Street Address:
(Express Scripts will keep this address on file for all orders from
City, ST, ZIP:
this membership until another shipping address is provided by
any person in this membership.)
Daytime phone:
Evening phone:
2
Patient/doctor information: Complete one section for each person with a prescription. If a person has
prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on
back). Send all prescriptions in the envelope provided.
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
3
Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and money orders
payable to Express Scripts, and write your member ID number on the front. You can enroll for e-check payments
and price medications at Express-Scripts.com, or call the Member Services phone number found on your ID card.
Number of prescriptions sent with this order:
Payment options:
e-check
Payment enclosed
Credit card
Send bill
For credit card payments:
Credit card number
Visa
MC
Discover
Amex
Diners
Expiration date
X
I authorize Express Scripts to charge this card for
all orders from any person in this membership.
M M Y Y
Cardholder signature
Rush the mailing of this shipment ($21, cost subject to change). NOTE: This will only rush the shipping,
not the processing of your order. Street address is required; P.O. box is not allowed.
DODMOFWB
Mailing instructions are provided on the back of this form.
Patient/doctor information continued
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
Important reminders and other information
Express Scripts will make all possible efforts, as
Check that your doctor has prescribed the maximum days’
appropriate by law, to substitute generic formulations
supply allowed by your plan (not a 30-day supply), plus
of medication, unless you or your doctor specifically
refills for up to 1 year, if appropriate. Also, ask your doctor
directs otherwise.
or pharmacist about safe, effective, and less expensive
generic drugs.
Pennsylvania and Texas laws permit pharmacists to
substitute a less expensive generic equivalent for a
Complete the Health, Allergy & Medication Questionnaire.
brand-name drug unless you or your doctor directs otherwise.
There may be a limit to the balance that you can carry
Check the box if you do not wish a less expensive
on your account. If this order takes you over the limit, you
brand or generic drug.
must include payment. Avoid delays in processing by using
Please note that this applies only to new prescriptions and to
e-checks or a credit card. (See Section 3 for details.)
any refills of that prescription.
For additional information or help, visit us at
Express-Scripts.com/TRICARE or call Member Services at
1.877.363.1303. TTY/TDD users should call
1.877.540.6261.
Federal law prohibits the return of dispensed controlled
substances.
Program: <<XXXXXXXXX>>
*6201*
Place your prescription(s), this form, and your
payment in the envelope provided. Be sure the
address shows through the window. Do not use
staples or paper clips.
EXPRESS SCRIPTS
PO BOX 52150
PHOENIX, AZ 85072-2150
DODMOFWB
Privacy Act Statement from the Department of Defense
To activate your account, please complete the fields below. Before doing so, you must read this
Privacy Statement from the Department of Defense.
Authority: 5 U.S.C. 301 (Departmental Regulations); 10 U.S.C. §§1095b-1095c, and §1097 (Medical
and Dental Care); 45 C.F.R. Part 160 and Subparts A and E of Part 164 (Health Insurance Portability and
Accountability Act); DTMA 04 (Medical/Dental Claim History Files); and, E.O. 9397, as amended (SSN).
Purpose: Information is being collected to provide pharmacy services to all TRICARE beneficiaries
Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the
Privacy Act, this information may specifically be used to verify beneficiary eligibility, to provide contracted
pharmacy benefits services, to authenticate and identify DoD affiliated personnel, and to register new
DoD civilian and military personnel and their authorized dependents for the purpose of obtaining medical
benefits or other benefits for which they are qualified.
Disclosure: Submission of this information is voluntary. However, failure to provide the requested
information may result in delayed processing of pharmacy services.
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