Walmart Home Delivery Prescription Order Form at a glance
What it is: Walmart Home Delivery Prescription Order Form (PH: 1-800-273-3455, Fax: 1-800-406-8976, P. O. Box 115112, Carrollton, TX 75011-5112, www.walmart.com/homedelivery, wmsrx@wal-mart.com).
Who signs: Sign at Signature and enter the Date.
Complete a separate form for each family member enrolling in the mail order service.
A filled-in Walmart Home Delivery Prescription Order Form example: a Self Pay refill
How to fill out Walmart Home Delivery Prescription Order Form, box by box
Patient Information
Under Patient Information, enter the Name (Last, First, Middle), Address, City, State and ZIP.
Enter the Home Phone, the Alternate Phone (if applicable), the Date of Birth, mark Male or Female and enter the Email Address.
Enter Allergies (drug, other), Health Conditions and Current Medications.
Insurance or Prescription Plan Information
Insurance or Prescription Plan Information is only required if you are new to the Home Delivery or if your information has changed since your last order.
If you are Medicare or Medicaid eligible, call 1-800-273-3455 to set up your profile.
Mark I am a new customer, My information has changed or I am a Self Pay customer.
Enter the Insurance ID #, Group#, Employer (if applicable), Insurance/ Plan Name, BIN# and PCN#.
Enter the Name of Insured/Policy Holder (Last, First, Middle), the Relationship to Insured/Policy Holder and the Insurance/Plan Ph#.
Mark Yes or No for Prefers Brand Drugs. Your co-pays may be significantly affected if you select Yes.
Healthcare Provider Information
Under Healthcare Provider Information, enter the Physician Name and the Phone number of the physician you see most often.
Prescription Details
Under Prescription Details, mark Refill, New Prescription or Transfer. For a transfer, enter the Pharmacy Name and Phone.
For refills, only enter Rx numbers from current prescription labels.
For new prescriptions and transfers, enter the medication name, quantity and strength.
Signature and Date
Sign at Signature and enter the Date.
More rules for Walmart Home Delivery Prescription Order Form
Your order may be delayed if any information is missing or incomplete.
To help insure the security and privacy of your financial data, Walmart Home Delivery does not request credit card information by fax or mail.
To pay for your order, allow time to process this form and then call 1-800-273-3455 with your payment information.
You may also enroll in the Rx Express Pay Program if you set up your account online at www.walmart.com/homedelivery.
Common questions about Walmart Home Delivery Prescription Order Form
Where do I file it?
Mail this form to P. O. Box 115112, Carrollton, TX 75011-5112.
Sources
[1] Walmart Home Delivery Prescription Order Form (no issuer file; served form) (the Official source link on this page).