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New Prescription Mail-In Form - rnbenefits.org
www.rnbenefits.orgPSO3249A-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.
New Prescription Fax Form - myjcbenefits.com
myjcbenefits.comAspirin Codeine NSAIDS (Only for CIII-CV prescriptions) NPI No.: Patient Information Ship to address Patient Name DOB Tel. Have questions? Please call us at