7-3103 bcbsal mof r4.indd

MAIL SERVICE
ORDER FORM
Enter ID # below if not shown or if different from above Use this form to order NEW and/or REFILL mail service pr der NEW and/or REFILL mail service pr escriptions. Please print in escriptions. Please print in BLUE
BLACK INK using CAPIT
VICE: Order refills and verify benefit information at efi lls and verify benefi t information at www.bcbsal.com Address Change/Shipping Information (Complete ONLY IF DIFFERENT or not shown above)
Use this address
for this order only.
Prescription Plan Sponsor or Company Name Rx Information - To order NEW prescriptions, mail the doctor's prescription(s) with this form.
If space is needed for more refill labels, you may: 1) attach labels to a blank piece of paper and send with this order form, or 2) print a
Refill Order Continuation Form at Caremark.com, or 3) call Caremark Customer Care.
Caremark is an independent company and does not provide Blue Cross and Blue Shield of Alabama products. Caremark is solely responsible for the pharmaceutical distribution of Mail Order Prescription Drugs to Blue Cross and Blue Shield of Alabama members. Blue Cross and Blue Shield of Alabama is an Independent Licensee of the Blue Cross and Blue Shield Association.
Unless otherwise directed, all prescriptions received on a single order form or in a
single envelope may be shipped together in one package.
Please turn over to provide additional information.
2007 Caremark. All rights reserved.
Fill in for up to two individuals who will receive prescriptions with this order.
Date new prescription(s) received from doctor: COMPLETE ALLERGY/HEALTH INFORMATION ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED
Health Conditions:
Date new prescription(s) received from doctor: COMPLETE ALLERGY/HEALTH INFORMATION ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED
Allergies:
Health Conditions:
Method of Payment/Shipping Information
Please make check or money order payable to Caremark. Include ID# on check/money order.
Amt. of check/money order: $
(Checks returned for insufficient funds will be subject to a processing fee of up to $40, depending on state law.) OR pay by credit or debit card (preferred). We accept VISA®, MasterCard®, Discover® and American Express®.
Fill in oval to charge most recently used credit card for this order and future orders for all individuals included in the family.
Fill in oval to charge most recently used credit card for this order only.
Your order will be shipped standard delivery at no charge. Allow To add, change, or update your credit card information, write in 10 to 14 days for standard delivery. If you require faster delivery, mark the appropriate oval below. Expedited delivery only affectsshipping time, not processing time of your order. Expedited shipments can only be sent to a street address, not a P.O. Box.
Fill in oval for expedited delivery:
Your credit card will be billed for prescription costs and expeditedshipping (if requested).
By submitting this form you acknowledge that eligibility under the prescriptionbenefit is subject to Plan verification and that you/your dependents do not haveprimary prescription coverage under any other plan.

Source: http://actcard.ua.edu/~hr/benefits/Documents/Order%20Form.pdf