Follow the steps to successfully complete your prescription order form.

1. Click the ‘Get Form’ button to access and open the Walmart Home Delivery form in your preferred editor.
2. Begin by filling out the patient information section. Provide details such as the patient's name (last, first, middle), address, city, state, home phone, ZIP code, alternate phone number, date of birth, email address, allergies, health conditions, and current medications.
3. Next, proceed to the insurance or prescription plan information section. Indicate if you are a new customer or if your information has changed. Enter your insurance ID number, group number, employer (if applicable), insurance or plan name, BIN number, PCN number, and the name of the insured or policy holder.
4. Complete the healthcare provider information by providing the name and phone number of the physician you visit most frequently.
5. In the payment information section, follow the instructions provided. You will need to call 1-800-273-3455 with your payment details after the form has been processed. If you wish, consider enrolling in the Easy Pay Program by setting up your account online.
6. Fill out the prescription details according to your needs. Choose whether you want a refill, new prescription, or transfer. Enter the required information such as medication name, quantity, and strength for each prescription.
7. Finally, sign and date the form to confirm the accuracy of the provided information before submitting it.

Complete your Walmart Home Delivery prescription order form online today for a hassle-free experience.