Follow the steps to successfully complete your order form online.

1. Press the ‘Get Form’ button to access the mail order form and open it in your chosen document editor.
2. In the patient information section, enter the last name, middle initial, date of birth, first name, and the relationship to the plan member (self, spouse, or dependent). Select the appropriate gender from the options provided.
3. Provide the shipping address by filling in the street address, city, state, and zip code. Include both home and work phone numbers for contact purposes.
4. In the health information section, indicate if the patient has any allergies or medical conditions by selecting 'Yes' or 'No.' If 'Yes,' list the specific allergies or conditions as prompted.
5. Enter the insurance information if applicable. Fill out the cardholder's last name, middle initial, first name, member ID, group ID, and group/employer name.
6. Choose the payment options by selecting a credit card type and entering the credit card number, name on the card, and expiration date. If paying via a checking account, include the account number and bank routing number, and remember to provide a voided check.
7. If the billing address is the same as the shipping address, select the appropriate option; otherwise, provide the billing address details.
8. Fill in the prescription information by enclosing any new prescriptions and listing the medication names, strengths, quantities, doctor’s name, doctor’s phone number, and the refill number, if applicable.
9. Sign and date the patient authorization section, certifying that all information provided is correct and authorizing the release of medical information.
10. Review all entered information for accuracy. Save your changes, and proceed to download, print, or share the completed form as needed.

Complete your documents online today for a seamless experience.