Champ va form 10 0426 meds by mail order form

You're looking for the VA Form 10-0426, "Medications by Mail Order Form"!

Here's a breakdown of the form:

Purpose: This form is used by veterans to request medications by mail order through the Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) program.

Who can use it: Eligible veterans, including those with a service-connected condition, can use this form to request medications by mail order.

What to include:

1. Veteran's information: Provide your name, Social Security number, and VA file number (if applicable).
2. Medication information: List the medications you need, including the name, dosage, and frequency of administration.
3. Prescription information: Include the prescription number, doctor's name, and date of prescription.
4. Mail order information: Specify the address where you want the medications to be mailed.
5. Authorization: Sign and date the form to authorize the VA to fill and mail your medications.

Where to submit it:

1. Mail: Send the completed form to the VA PBM program at the address listed on the form.
2. Online: You can also submit the form online through the VA's online portal, My HealtheVet.

Tips:

• Make sure to complete the form accurately and legibly.
• Keep a copy of the form for your records.
• If you have any questions or concerns, contact the VA PBM program or your healthcare provider.

Remember to always follow the instructions provided with the form and to consult with your healthcare provider before making any changes to your medication regimen.