Medco mail order prescription form

Here is a sample Medco mail order prescription form:

Medco Mail Order Prescription Form

Patient Information:

• Name: _____
• Date of Birth: __
• Address: __
• City, State, ZIP: _____

Prescription Information:

• Prescription Number: ___
• Doctor's Name: __
• Doctor's Phone Number: __
• Doctor's Fax Number: ___

Medication Information:

• Medication Name: _____
• Strength: __
• Quantity: __
• Refills: ___

Instructions:

• Take one tablet by mouth once daily
• Take with food
• Do not crush or chew

Special Instructions:

• Do not take with other medications
• Do not take if you have a history of kidney disease

Authorization:

• I authorize Medco to fill and mail my prescription as directed.
• I understand that Medco will not fill my prescription if it is not valid or if I do not have a valid prescription from my doctor.
• I understand that Medco will not fill my prescription if it is not covered by my insurance plan.

Signature:

• I hereby certify that the information provided is accurate and complete.
• I understand that Medco will not fill my prescription if it is not valid or if I do not have a valid prescription from my doctor.
• I understand that Medco will not fill my prescription if it is not covered by my insurance plan.

Signature: __ Date: ___

Additional Information:

• If you have any questions or concerns about your prescription, please call Medco at 1-800-MEDCO-4U (1-800-633-2644).
• You can also visit our website at www.medco.com for more information.

Please note that this is just a sample form and the actual form may vary depending on the specific needs of your patient and the requirements of your insurance plan.