Medco mail order prescriptions form

Here is a sample Medco Mail Order Prescriptions form:

Medco Mail Order Prescriptions 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: ___

Medications to be Filled:

• Medication Name: _____
• Dosage: __
• Quantity: ___
• Refill Number: _____

Payment Information:

• Payment Method: _____
  • Check (payable to Medco)
  • Credit Card (Visa, Mastercard, or Discover)
  • Electronic Funds Transfer (EFT)
• Payment Amount: _____

Authorization:

• I authorize Medco to fill the above prescription(s) and to bill my insurance carrier or me directly for the cost of the medication(s).
• I understand that Medco may contact my doctor or pharmacist to verify the prescription and to obtain any necessary information.
• I understand that Medco may require additional information or documentation to process my prescription.

Signature:

• I hereby sign this authorization and acknowledge that I have read and understood the terms and conditions of this form.

Signature: _ Date: ___

Additional Information:

• If you have any questions or concerns about this form, please contact Medco's Customer Service department at 1-800-MEDCO-4U (1-800-633-2644).
• You can also fax this form to Medco at 1-800-633-2645 or mail it to Medco Mail Order, P.O. Box 2058, Franklin, TN 37064.

Please note that this is a sample form and may not be the exact form used by Medco. It's always best to check with Medco or your doctor's office for the most up-to-date and accurate information.