Cigna Home Delivery PDF Details

The Cigna Home Delivery Pharmacy Prescription Order Form provides a convenient avenue for customers seeking to order new or refill prescription medications without leaving their homes. Essential to ensure the accuracy and security of the medication delivery process, this form requires the completion of various sections with information ranging from insurance cardholder details to specific medication requests. It emphasizes the need for clear printing in blue or black ink, and it meticulously guides the user through steps that include providing contact information, detailing allergies and health conditions, selecting a shipping method, and specifying the payment method. Importantly, it caters to both new prescriptions and refills, highlighting options for shipping, including no-cost standard delivery and expedited options at additional charges. The form also accommodates various payment types, including checks, money orders, and credit or debit cards, while offering detailed instructions for submitting new prescriptions. This form signifies Cigna's commitment to providing accessible pharmaceutical care, reinforcing its convenience through options for online ordering and ensuring patients' health needs are met efficiently and effectively.

QuestionAnswer
Form NameCigna Home Delivery
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescigna home delivery refill form, cigna prescription fax form for physicians, cigna mail order form, cigna home delivery fax form

Form Preview Example

Cigna Home Delivery Pharmacy

*10450001*

 

Prescription Order Form

10450001

514

 

 

Please complete this form for NEW and REFILL prescription medication. You can also order refills online at the website on your ID card.

Print all information clearly as shown in the sample below using BLUE or BLACK ink.

1 234A BCD

Fill in the applicable ovals completely ().

Step 1: Insurance Cardholder Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

email _______________________________________________________

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Person completing __________________________________________

 

 

 

 

 

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Order updates, reminders and other educational information may be sent to the email

 

 

 

 

 

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address above for the following individuals: ___________________________________________

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_______________________________________________________________________________________

L A S T

N A M E

 

 

 

F I R S T

N A M E

 

 

 

 

A D D R E S S

L I N E

1

 

 

 

 

 

 

 

 

 

A D D R E S S

L I N E

2

C I T Y

 

 

 

 

 

 

 

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Address above is a one time address

 

 

 

 

Step 2: Allergies & Health Conditions

 

 

 

Allergies

 

 

Health Conditions

 

 

 

 

 

 

 

 

 

 

New customers must complete this section.

None

Penicillin Sulfa Codeine/Morphine Aspirin Erythromycin

NSAIDS below)(listOther

Diabetes

BloodHigh Pressure Asthma

GI/GERD

CholesterolHigh

If left blank will mean no known drug allergies or

 

 

 

 

 

 

 

 

no change from information provided previously to

 

 

 

 

 

 

 

 

Cigna Home Delivery Pharmacy.

 

 

 

 

 

 

 

 

 

 

Name (start with cardholder)

Date of Birth

 

 

 

 

 

 

 

 

F I

R S T

 

N A M E

 

M M / D D / Y Y

 

 

 

 

 

 

 

 

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A M E

 

 

 

 

 

 

 

 

 

 

F I

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M M / D D / Y Y

 

 

 

 

 

 

 

 

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A M E

 

 

 

 

 

 

 

 

 

 

F I

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N A M E

 

M M / D D / Y Y

 

 

 

 

 

 

 

 

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M M / D D / Y Y

 

 

 

 

 

 

 

 

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A M E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Other (list below)

Please write the individual’s name and list their other allergies and other health conditions referenced above:

“Cigna" is a registered service mark, and the “Tree of Life” logo and “Cigna Home Delivery Pharmacy” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation.

“Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

Rev. 2.0 1/12

10450002 *10450002*

Step 3: Shipping Method

Refrigerated shipments will be expedited at no additional cost. You are responsible for the cost of SPECIAL SHIPPING which expedites carrier delivery time only. Order processing is not affected by SPECIAL SHIPPING. These costs may be subject to change by carrier without prior notification and may vary depending on weight and zone.

Standard Shipping

$0.00

USPS Priority Mail

2 - 3 Days

$9.25

Overnight Delivery $17.95

Step 4: Method of Payment

 

 

 

 

 

Check

Money Order

Please make check or money order payable to Cigna Home Delivery Pharmacy

Total payment enclosed (excluding credit card payment):

$

,

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VISA

Discover

 

MasterCard

American Express

Credit / Debit Card #

/

Expiration Date

Use Credit / Debit Card on File

Last 4 digits of Credit / Debit Card

Expiration Date

 

 

 

/

I allow Cigna Home Delivery Pharmacy to bill my credit / debit card for this and all future orders. I understand that my credit

/debit card will be billed the following amounts in effect at the time my order is filled: any applicable copayment(s), coinsur- ance and/or deductible(s), payments due for any medications not covered, plus any special shipping costs.

Step 5: Refill Prescriptions

Print Prescription Number Here

Individual’s Name _______________________

Date of Birth ___________________________

Drug Name ____________________________

Print Prescription Number Here

Individual’s Name _______________________

Date of Birth ___________________________

Drug Name ____________________________

Print Prescription Number Here

Individual’s Name _______________________

Date of Birth ___________________________

Drug Name ____________________________

Print Prescription Number Here

Individual’s Name _______________________

Date of Birth ___________________________

Drug Name ____________________________

Step 6: New Prescriptions

Please write the date of birth and the Cigna ID on the back of each prescription.

 

Check (

) One

Check

 

 

 

 

 

 

 

 

Do Not

( ) if

 

 

Fill

Fill

Brand

 

Individual’s Full Name

Date of Birth Now

Now

Medication Name & Strength Only

Doctor’s Full Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy law allows pharmacists to substitute a less expensive generically equivalent medication for a brand name medication unless you or your doctor request the brand. By checking ( ) “Brand Only”, you may be responsible for a higher cost.

Remember to include the original prescription(s) from your doctor(s).

You can call us at 1.800.835.3784 or visit the website on your ID card. You can also write to us or

mail this order form to Cigna Home Delivery Pharmacy, PO Box 1019, Horsham PA 19044.

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stage 1 to filling in cigna home delivery pharmacy form

You need to submit the Name start with cardholder, Date of Birth, c n e P, e n o N, u S, e n h p r o M e n e d o C, t y r E, S D A S N, n i r i p s A, r e h O, e b a D, t s e o h C h g H, r e h O, e r u s s e r P, and a m h t s A box with the demanded particulars.

cigna home delivery pharmacy form Name start with cardholder, Date of Birth, c n e P, e n o N, u S, e n h p r o M e n e d o C, t y r E, S D A S N, n i r i p s A, r e h O, e b a D, t s e o h C h g H, r e h O, e r u s s e r P, and a m h t s A fields to fill

You need to point out the essential particulars in the Refrigerated shipments will be, Standard Shipping, USPS Priority Mail, Days, Overnight Delivery, Step Method of Payment, Check, Money Order, Please make check or money order, Total payment enclosed excluding, VISA, Discover, MasterCard, American Express, and Credit Debit Card field.

stage 3 to entering details in cigna home delivery pharmacy form

The Individuals Name Date of Birth, Individuals Name Date of Birth, Print Prescription Number Here, Print Prescription Number Here, Individuals Name Date of Birth, Individuals Name Date of Birth, Step New Prescriptions, Include original written, Please write the date of birth and, Individuals Full Name, Date of Birth, Check One, Do Not Fill Now Medication Name, Fill Now, and Check space is where both parties can put their rights and obligations.

part 4 to completing cigna home delivery pharmacy form

Finalize by checking the next sections and filling in the proper information: Pharmacy law allows pharmacists to, and Remember to include the original.

cigna home delivery pharmacy form Pharmacy law allows pharmacists to, and Remember to include the original blanks to fill

Step 3: As you select the Done button, your finalized document can be simply transferred to any kind of your gadgets or to electronic mail indicated by you.

Step 4: Generate copies of your file - it will help you avoid upcoming concerns. And don't get worried - we don't display or read your data.

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