Transcription of Walgreens Mail Service
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Walgreens Mail Service
Prescription Benefit Provider/Pharmacy Drug Insurance: Walgreens Mail ServiceRegistration and Prescription Order FormYour Employer Name:_____To quickly register, visit print clearly using only BLACK INKand UPPERCASE letters.*197*197ID Number (located on card)Suffix (if on card)Group NumberLast NameFirst NamePermanent Address 1 CityStateZIP CodeDaytime PhoneEvening PhoneE-mail Address (to receive information regarding the processing of your order)Suffix (if on card)Dependent Last NameDependent First NameE-mail Address (to receive information regarding the processing of your order)Prescriber Last NamePrescriber First InitialPrescriber PhonePrescriber FaxPrescriber Last NamePrescriber First InitialPrescriber PhonePrescriber FaxAllergiesAspirinCephalosporinCodeine derivativesMorphine derivativesPenicillinSulfa drugsNone knownOther (Use lines below.)
Prescription Benefit Provider/Pharmacy Drug Insurance: Walgreens Mail Service Registration and Prescription Order Form Your Employer Name:_____ To quickly register, visit www.walgreensmail.com.
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