Silverscript Mail Order Form PDF Details

Navigating the process of obtaining medications through mail services can simplify the lives of many, and the SilverScript Mail Order Form plays a crucial role in facilitating this convenience. Operated by CVS Caremark, this specific form allows individuals enrolled in the prescription plan to order new prescriptions or refill existing ones directly through mail. Detailed instructions guide users to fill out the form with a preference for blue or black ink and capital letters, ensuring clarity and ease of processing. The form accommodates both new and refill prescriptions, with a clear emphasis on utilizing online or phone services for faster refill orders. It provides a section for updating shipping addresses to ensure medications are accurately delivered. Moreover, individuals can specify any new allergies or health issues, making personalized care a priority. The form also includes options for payment methods, including electronic checks, credit or debit cards, and the conventional check or money order, alongside instructions for those choosing to use these payment forms for the first time or updating their details. Additionally, the document outlines shipping options, catering to those needing expedited delivery, thereby offering flexibility and control over the delivery timeline. This comprehensive approach by the SilverScript Mail Order Form underlines a commitment to accessible, tailored healthcare logistics.

QuestionAnswer
Form NameSilverscript Mail Order Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescvs silverscript mail order, silverscript mail order pharmacy, silver scripts pharmacy, does silverscript have mail order

Form Preview Example

Mail Service Order Form

Enter ID # below if not shown or if different from above

Prescription Plan Sponsor or Company Name

Mail this form to:

CVS CAREMARK PO BOX 94467 PALATINE, IL 60094-4467

Please use blue or black ink, capital letters, and fill in both sides of this form.

New Prescriptions - Mail your new prescriptions with this form.

Number of New prescriptions:

ReÞlls - Order by Web, phone, or write in Rx number(s) below.

Number of ReÞll prescriptions:

FOR FASTEST SERVICE, order refills at www.caremark.com or call the number on your prescription benefit identification card.

AShipping Address. To ship to an address different from the one printed above, please make changes here.

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

MI Suffix (JR, SR)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt./Suite #

 

 

 

 

Use this address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for this order only.

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone #:

-

-

Evening Phone #:

-

-

ReÞlls. To order mail service refills, enter your prescription number(s) here.

1)

2)

3)

4)

5)

 

6)

 

7)

 

8)

We may package all of these prescriptions together unless you tell us not to.

©2011 Caremark. All rights reserved. P13-N

Business days are only Monday-Friday

CTell us about the people getting prescriptions. If there are more than two people, please complete another form.

1st person with a refill or new prescription. This person needs:

 

 

 

Spanish forms and labels

Last Name

 

 

 

 

 

 

First Name

 

 

 

MI

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(JR,SR)

 

 

 

 

Gender:

M

F

Date of Birth:

 

 

 

 

 

 

 

 

 

MM-DD-YYYY

 

 

 

 

 

 

Your E-Mail:

 

 

 

 

 

 

Date new prescription written:

 

 

Doctor’s Last Name

 

 

 

Doctor’s First Name

 

 

Doctor’s Phone #

 

 

Tell us about new allergies or health information for this person. Only tell us about new information.

Allergies:

None

 

Aspirin

Cephalosporin

Codeine

Erythromycin

Peanuts

Penicillin

Sulfa

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

Health Information:

Arthritis

Asthma

Diabetes

Acid Reflux

 

Glaucoma

Heart Problem

High Blood Pressure

High Cholesterol

Migraine

Osteoporosis

Prostate Issues

Thyroid

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2nd person with a refill or new prescription. This person needs:

 

 

 

Spanish forms and labels

Last Name

 

 

 

 

 

 

First Name

 

 

 

MI

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(JR,SR)

 

 

 

 

Gender:

M

F

Date of Birth:

 

 

 

 

 

 

 

 

 

MM-DD-YYYY

 

 

 

 

 

 

Your E-Mail:

 

 

 

 

 

 

Date new prescription written:

 

 

Doctor’s Last Name

 

 

 

Doctor’s First Name

 

 

Doctor’s Phone #

 

 

Tell us about new allergies or health information for this person. Only tell us about new information.

Allergies:

None

 

Aspirin

Cephalosporin

Codeine

Erythromycin

Peanuts

Penicillin

Sulfa

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

Health Information:

Arthritis

Asthma

Diabetes

Acid Reflux

 

Glaucoma

Heart Problem

High Blood Pressure

High Cholesterol

Migraine

Osteoporosis

Prostate Issues

Thyroid

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSpecial Instructions:

How would you like to pay for this order? Fill in the oval to choose a payment.

Electronic Check. Pay from your bank account. First time users register online or call Customer Care.

Bill Me Later¨. Works like a credit card. First time users register online or call Customer Care.

Credit or Debit Card. (VISA®, MasterCard®, Discover®, or American Express®)

Fill in this oval to use your card on file.

Fill in this oval to use a new card or to update your card expiration date.

Exp.Date

MMYY

Check or Money Order. Amount: $

.

Make check or money order out to CVS Caremark.

Write your prescription benefit ID number on your check or money order.

If your check is returned, we will charge you up to $40.

Payment for Balance Due and Future Orders: If you chose Electronic Check, Bill Me Later®, or a Credit or Debit Card, we will also use it to pay for any balance that you owe and for future orders.

Fill in this oval if you DO NOT want to use this payment method for future orders.

Credit Card Holder Signature/Date

Regular delivery is free and will take 7 to 10 days from the day you send this form.

If you want faster delivery, choose:

2nd Business Day ($17) Next Business Day ($23)

• Faster delivery charges may change.

Faster delivery is for shipping time, not processing time.

Faster delivery can only be sent to a street address, not a PO box.

MOF WEB 0711 MTP FILLABLE

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1. Fill out the silver script pharmacy with a group of major blanks. Gather all of the information you need and ensure nothing is forgotten!

The right way to prepare silverscript caremark step 1

2. Once the first part is filled out, go on to type in the relevant information in these: We may package all of these, and Caremark All rights reserved PN.

Step number 2 in submitting silverscript caremark

Be very mindful when filling in Caremark All rights reserved PN and Caremark All rights reserved PN, because this is the section in which many people make some mistakes.

3. In this step, look at st person with a refill or new, First Name, Spanish forms and labels, Suffix JRSR, Your EMail, Date new prescription written, Gender M, Date of Birth MMDDYYYY, Doctors Last Name, Doctors First Name, Doctors Phone, Tell us about new allergies or, Cephalosporin, Erythromycin, and Codeine. All of these need to be filled out with highest focus on detail.

Completing segment 3 in silverscript caremark

4. This next section requires some additional information. Ensure you complete all the necessary fields - Your EMail, Date new prescription written, Gender M, Date of Birth MMDDYYYY, Doctors Last Name, Doctors First Name, Doctors Phone, Tell us about new allergies or, Cephalosporin, Erythromycin, Peanuts, Codeine, Penicillin, Sulfa, and Aspirin Other - to proceed further in your process!

Tips to complete silverscript caremark portion 4

5. As you near the final parts of the file, there are a few more points to undertake. Mainly, Check or Money Order Amount, Make check or money order out to, Fill in this oval if you DO NOT, MOF WEB MTP FILLABLE, Credit Card Holder SignatureDate, Regular delivery is free and will, nd Business Day Business days, Next Business Day MondayFriday, are only, and Faster delivery charges may must all be done.

Filling out part 5 in silverscript caremark

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