Transcription of Walgreens Mail Service
1 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.)
2 MemberDependentMemberDependentMember InformationDependent InformationFill in the applicable circles completely ( ). Not all Group and ID number boxes may be Address 2*only applies if mailing in enrollment form with a prescription enclosedEasy-open capsLarge-print vial labelsSpanish vial labelsAuto Refill*Health ConditionsArthritisAsthmaDiabetesGlaucom aHeart diseaseHypertensionPregnancyThyroid diseaseNone knownOther (Use lines at left.)Please CompleteOrder PreferenceMaleFemaleDate of Birth [MM/DD/YYYY]MaleFemaleDate of Birth [MM/DD/YYYY]//// Member Alternate Shipping InformationAlternate Address 1 CityStateZIP CodeAlternate PhoneEnd Date [MM/DD/YY] order InformationMail to: Walgreens mail Service , Box 29061, Phoenix, AZ 85038-9061It is standard pharmacy practice to substitute generic equivalents for brand-name drugs whenever possible.
3 Walgreens mail Service will dispense an FDA-approved generic equivalent whenever available, permitted by your prescriber, and allowed by state law. By submitting this form , you have authorized release of all information to Walgreens mail Service (and other necessary parties) as required to process your order under your benefit your prescription with this form . A refill order form and return envelope will be included with your Date [MM/YY]Check made payable to Walgreens mail ServiceCharge credit card below for this order onlyPlace credit card below on file for this and all future ordersPlease allow 14 days to receive your Card NumberIIff aa ddeeppeennddeenntt ss mmeeddiiccaattiioonn nneeeeddss ttoo bbee ddeelliivveerreedd ttoo aa ddiiffffeerreenntt aaddddrreessss,, pplleeaassee ssuubbmmiitt aa sseeppaarraattee AAddddiittiioonnaall ffoorrmmssaarree aavvaaiillaabbllee aatt shipment onlyTemporary address change for dates indicated to the rightWe accept American Express , Discover , MasterCard , and Visa *198*198 Total number of prescriptions in this order .
4 Regular ShippingNO CHARGENext Business Day ($ )$ 2nd Business Day ($ )$ Total Payment Due ..$ Total included for copay(s) ..$Shipping prices may be subject to change by carrier without notification and may vary depending upon weight and Date [MM/DD/YY]Payment Options Payment is required at time of order . Please do not send cash. 2007 Walgreen Co. All rights authorize Walgreens mail Service to charge my credit card for services for which I am financiallyresponsible. If the credit card provided is not able to fulfill payment for any reason, I agree to pay my statement balance upon receipt of the statement and understand that failure to do so may result in discontinuation of pharmacy Signature DateAlternate Address 2//// /..PMM-MC-PRD00013/1-mmyy
