Mail Service Order Form

Mail this form to:

Enter ID # below if not shown or if different from above

Number of New prescriptions:

Number of Refill prescriptions:

Please use blue or black ink, capital letters, and fill in both sides of this form.

Shipping Address. To ship to an address different from the one printed above, please make changes here.

New Prescriptions - Mail your new prescriptions with this form.

Refills - Order by Web, phone, or write in Rx number(s) below.

Refills. To order mail service refills, enter your prescription number(s) here.

A

B

Use this address for this order only.

Apt./Suite #

City State ZIP Code

Street Name

-- --Daytime Phone #: Evening Phone #:

Last Name First Name MI Suffix (JR, SR)

1) 2) 3) 4)

5) 6) 7) 8)

Prescription Plan Sponsor or Company Name

FOR FASTEST SERVICE order re¿lls at www.caremark.com or call the number on your prescription bene¿ t identi¿ cation card.

CVS CAREMARK PO BOX 2110 PITTSBURGH, PA 15230-2110

We may package all of these prescriptions together unless you tell us not to.

©2010 Caremark. All rights reserved. P13-N

C Tell us about the people getting prescriptions. If there are more than two people, please complete another form.

1st person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels Suffix (JR,SR)

Gender: M Date of Birth:F Your E-Mail: Date new prescription written:

Doctor’s Last Name Doctor’s First Name Doctor’s Phone # Tell us about new allergies or health information for this person. Only tell us about new information. Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin

Sulfa Other: Health Information: Arthritis Asthma Diabetes Acid Reflux Glaucoma Heart Problem

High Blood Pressure High Cholesterol Migraine Osteoporosis Prostate Issues Thyroid Other:

2nd person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels Suffix (JR,SR)

FGender: M Date of Birth: Your E-Mail: Date new prescription written:

Doctor’s Last Name Doctor’s First Name Doctor’s Phone # Tell us about new allergies or health information for this person. Only tell us about new information. Allergies:

Health Information:

ErythromycinCephalosporin CodeineAspirinNone Sulfa Other:

Peanuts

Arthritis Asthma Diabetes Acid Reflux Glaucoma High Blood Pressure Other:

High Cholesterol Migraine Osteoporosis Prostate Issues

Penicillin

Heart Problem Thyroid

D Special Instructions:

E How would you like to pay for this order? Fill in the oval to choose a payment.

Electronic Check. Pay from your bank account. First time users register online or call Customer Care.

Bill Me Later®. Works like a credit card. First time users register online or call Customer Care.

Credit or Debit Card. (VISA®, MasterCard®, Discover®, or American Express®) Fill in this oval to use your card on file. Fill in this oval to use a new card or to update your card expiration date.

Check or Money Order. Amount: $ Credit Card Holder Signature/Date

Exp.Date

. Regular delivery is free and will take 7 to 10• Make check or money order out to CVS Caremark. days from the day you send this form.• Write your prescription bene¿t ID number on your If you want faster delivery, choose:

check or money order. 2nd Business Day ($17) Business daysare only

Next Business Day ($23) Monday-Friday • If your check is returned, we will charge you up to $40. Payment for Balance Due and Future Orders: If you chose • Faster delivery charges may change.Electronic Check, Bill Me Later®, or a Credit or Debit Card, • Faster delivery is for shipping time, not processing time.we will also use it to pay for any balance that you owe and • Faster delivery can only be sent to a street address,for future orders. not a PO box.

Fill in this oval if you DO NOT want to use this payment method for future orders.

49-MOF 0210 PIT

Non-Discrimination Statement and Foreign Language Access

We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits.

If you or someone you're assisting is disabled and needs interpretation assistance, help is available at the contact number posted on our website or listed in the materials included with this notice (TDD: 711).

Free language interpretation support is available for those who cannot read or speak English by calling one of the appropriate numbers listed below.

If you think we have not provided these services or have discriminated in any way, you can file a grievance by emailing contact@hcrcompliance.com or by calling our Compliance area at 1-800-832-9686 or the U.S. Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 or 1-800-537-7697 (TDD).

Si usted, o alguien a quien usted esta ayudando, tiene preguntas acerca de este plan de salud, tiene derecho a

obtener ayuda e informaci6n en su idioma sin costo alguno. Para hablar con un interprete, llame al 1-844-396-0183 . (Spanish)

~~•. d••~amM~fia . ~~~*••tt~~~~~~ . •~m~~•~•~m~~~•M~m ,~,o 5i3'~-i.Ili~~~l~ . ~w~ 1-844-396-01880 (Chinese)

Neu quy vi, ho~c la ngLrai ma quy vi dang giup da, co nhLi'ng cau hoi quan tam ve chuang trlnh st'.rc khoe nay, quy

vi se duqc giup da v&i cac thong tin b~ng ngon ngLi' cua quy vi mi~n phf. De n6i chuy~n v&i m(>t thong dich vien,

xin gQi 1-844-389-4838 (Vietnamese)

01 :c\~_!i!_~OJl-tJ-o~~ ~ii~NgJ-~:: ~go1~J 0 AI~1-844-396-0187£ <2!~oH ~~Al.2.

-111 o~ QI l:l I-§- ¥'a fil 0 I ~~ Oj £ .!i.2~ c ~ LI q. (Korean)

Kung ikaw, o ang iyong tinutulungan, ay may mga katanungan tungkol sa planong pangkalusugang ito, may

karapatan ka na makakuha ng tu long at impormasyon sa iyong wika nang walang gastos. Upang makausap ang

isang tagasalin, tumawag sa 1-844-389-4839. (Tagalog)

Ecm-1 y Bae 1-11n1 n1-1u,a, KOTopoMy Bbl noMoraeTe, 1-1Me10TCR sonpocb1 no noBOAY Bawero nnaHa MeA1-1U,l-1HCKoro

06cny>1<1-1saH1-1R, rn Bbl 1-1MeeTe npaso Ha 6ecnnaTHoe nony4eH1-1e noMow,1-1 1-1 1-1H<!>opMau,1-11-1 Ha pyccKoM R3b1Ke. ,ll,nR pa3rosopa c nepeBOA41-1KOM no3BOHl-1Te no Tenect>oHy 1-844-389-4840. (Russian)

wL. _,1..-..ll_, o.x:.L.......ll ~ J~I ~ t..?JI 4..ili 'o~ ~\ ~ U""' ~ ~\ o.x:.L....:i ~ c..S..i.l _,\ 4...i.l u\.S uJ {Arabic) 1-844-396-0189 y J,....:.:il r:-fa C"' 6..l.:..:ill.A..ilS:i ~I l.J3..l l.J.4 ~ ~..J_,y.::.JI

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