New prescription mail in form

New Prescription Mail-In Form - rnbenefits.org

PSO3249A-KS_120110 Prescription Solutions by OptumRx, P.O. Box 2975, Mission, KS 66201 New Prescription Mail-In Form Please use black or blue ink and mail this completed order form with your new prescription(s). DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.

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Medication Order Form Aetna Rx Home Delivery

Aetna Rx Home Delivery® Medication Order Form Mail this form to: Please use blue or black ink, capital letters, and fill in both sides of this form. Shipping Address. Refills - Order by Web, phone, or write in Rx number(s) below. Refills. To order mail service refills, enter your prescription …

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1. Your information: Authorization to Release Protected ...

2. Giving others access to your medical records (called proxy access) You may grant another person full access to your records. This might be a parent, spouse, adult child or