Get Vacation/extended Refill Request Form - Bluecross Blueshield Of ...

Filling out the Vacation/Extended Refill Request Form is an essential step for users seeking early prescription refills. This guide provides a clear, step-by-step process for completing the form online to ensure a seamless experience in managing your prescription needs.

Follow the steps to successfully complete your form online

1. Click the ‘Get Form’ button to access the Vacation/Extended Refill Request Form and open it for editing.
2. In Section A, provide the patient information. Fill in the Member ID Number, Date of Birth, First Name, Last Name, Address, City, State, and ZIP code accurately to ensure proper processing of the request.
3. Move to the Request Detail section. Clearly explain the reason for your request in the designated area, including any specific details relevant to your situation.
4. Complete the medication details by providing the strength, quantity, and prescription information for each medication you want to request a refill for (labelled RX 1 through RX 5). Ensure all data is precise.
5. Indicate the prescription supply you are requesting in the provided field and include your intended Date of Departure and Date of Return.
6. Specify the number of months and days you will be away, as this will affect the total supply requested.
7. In the Member Signature section, sign to confirm the information provided is accurate, and date the form to validate your request.
8. Finally, review the completed form for any inaccuracies or missing information. Save changes, and download, print, or share the form as necessary to send it to BlueCross BlueShield of Tennessee.

Complete your Vacation/Extended Refill Request Form online to manage your prescription needs efficiently.