Follow the steps to complete your mail order form

1. Click ‘Get Form’ button to access the mail order form and open it in your editor.
2. Fill in the patient’s first and last name in the designated fields at the top of the form. Ensure that the names are spelled correctly for accurate processing.
3. Provide the street address, city, state, and zip code of the patient. This information is crucial for delivering the medications.
4. Enter the phone number for contact purposes, ensuring it is a reachable number in case the pharmacy needs to follow up.
5. Input the Caremark insurance information, including the ID number and name of the employee, to verify prescription coverage.
6. List RX numbers and medication names for each prescription refill needed. If there are multiple medications, ensure each is clearly stated with their respective RX numbers.
7. If applicable, indicate any specific requests regarding generic substitutions in the provided section to avoid additional fees.
8. Provide payment information by selecting the preferred credit card method (American Express, MasterCard, Discover, or Visa) and fill in the card details, including the card number, expiration date, and security code.
9. Complete health concerns and allergies sections to assist pharmacists in monitoring for any drug interactions.
10. Finalize the form by signing it where indicated, then save the changes, download, print, or share the completed form as necessary for mailing purposes.

Complete your Penn Medicine Radnor Pharmacy Mail Order Form online today for a smoother prescription experience.