formulario de pedido por correo
Contents
1. encuentra en su tarjeta de identificaci n su fecha de nacimiento y su direcci n postal Eso es todo Despu s de que CVS Caremark reciba su orden y pago si es requerido tardar aproximadamente 10 d as para que usted reciba sus medicamentos Descubra la ventaja de recibir sus medicamentos recetados directamente en su hogar Tambi n existe un n mero de tel fono gratuito automatizado para ordenar sus renovaciones 24 horas al d a los 7 d as de la semana Si usted no recibe su orden en aproximadamente 10 d as por favor llame a CVS Caremark al 888 277 4144 TTY TDD 800 231 4403 Opciones utiles para renovar sus medicamentos Cuando utiliza el Programa de Servicio de Farmacia por Correo de CVS Caremark la informaci n que le enviamos con su pedido mostrar la fecha en que usted puede renovar sus medicamentos y la cantidad de veces que le quedan para volver a renovar Si solicita una renovaci n de sus medicamentos demasiado pronto CVS Caremark le notificar cuando sea el momento Plan Molina Dual Options MyCare Ohio Medicare Medicaid Si necesita ayuda con cualquier asunto relacionado con el medicamento o si tiene preguntas acerca de la cobertura de medicamentos llame al n mero de tel fono gratuito de nuestro Departamento de Servicios para Miembros al 855 665 4623 TT Y TDD al 711 De lunes a viernes de 8 00 a m a 8 00 p m hora local El Plan Molina Dual Options MyCare Ohio Medicare Medicaid es un plan de s2. if not shown or different from above a SA Prescription Plan Sponsor or Company Name Rees DIRECTIONS Print in BLUE or BLACK ink using CAPITAL letters Fill in ovals completely Complete both sides of form To order new prescriptions Mail your prescription s with this form of new prescriptions To order refills Order by Web phone or write in Rx number s below of refill prescriptions FOR FASTEST SERVICE order refills at www caremark com or call the number on your prescription benefit identification card SHIPPING ADDRESS IF NOT SHOWN OR DIFFERENT FROM ABOVE O A Ni A Last Name First Name MI Suffix JR SR a T T lt lt 2 Street Address Apt Suite 5 0 Use this Address 3 for this order only 5 a City State ZIP Code a Daytime Phone Evening Phone z REFILL INFORMATION To order mail service refills enter your prescription number s here 1 2 3 4 5 6 7 8 Prescriptions sent in one envelope may be shipped together unless you request otherwise EG o 32657MEDO713 2008 Caremark All rights reserved P12 N e FILL IN FOR UP TO TWO PEOPLE WHO WILL RECEIVE PRESCRIPTIONS WITH THIS ORDER E 1st PERSON ORDERING A PRESCRIPTION O Easy onen Gans O Pantin Spanish QO Suffix JR SR Gender O M QOF Date
3. unless a different form of payment is provided It will also be charged for any outstanding balance due O Fill in oval if you DO NOT want the selected payment method to be automatically charged for future orders MTP MOF 1208 32657MED0713 O Next Business Day 23 per order Charges subject to change Faster delivery options only affect shipping time not processing time and can only be sent to a street address not a P O box
4. 00 BRMOLINA FHWyCareOhio BHE H wea ad Medicare Medicaid Your Extended Family Programa de Servicio de Farmacia por Correo de CVS Caremark Gu a del usuario Para el Plan Molina Dual Options MyCare Ohio Medicare Medicaid Es f cil empezar el servicio Si necesita surtir su receta de inmediato pida a su m dico que le haga dos recetas m dicas de sus medicamentos a largo plazo e La primera para un suministro a corto plazo p ej 30 dias para surtir de inmediato en una farmacia de la red e La segunda para un suministro de la mayor cantidad de d as permitidos un suministro de hasta 90 d as con un m ximo de tres renovaciones si es apropiado para enviarla a CVS Caremark Preg ntele a su m dico acerca de c mo obtener una receta m dica por 90 d as Ya sea que utilice el Programa de Servicio de Farmacia por Correo de CVS o compre sus medicamentos en una farmacia minorista dentro de la red hable con su m dico hoy mismo para obtener una receta m dica por 90 d as y as ahorrar dinero Las ventajas de usar el servicio por correo Si toma uno o m s medicamentos de mantenimiento puede ahorrar tiempo y dinero con el servicio por correo y recibirlos en su hogar Esto significa menos viajes a la farmacia y a la gasolinera Elija entre 4 maneras para ordenar e Opci n 1 Correo Complete y env e por correo el Formulario de pedido a CVS Caremark Mande el formulario y pago a la direcci n impresa en el formulari
5. VICE ORDER FORM V e CAREM a Mail order form to holas CVS CAREMARK MTP STD PO BOX 94467 PALATINE IL 60094 4467 Enter ID if not shown or different from above Please fold here Please fold here Prescription Plan Sponsor or Company Name fn DIRECTIONS Print in BLUE or BLACK ink using CAPITAL letters Fill in ovals completely 0 Complete both sides of form To order new prescriptions Mail your prescription s with this form of new prescriptions To order refills Order by Web phone or write in Rx number s below of refill prescriptions FOR FASTEST SERVICE order refills at www caremark com or call the number on your prescription benefit identification card SHIPPING ADDRESS IF NOT SHOWN OR DIFFERENT FROM ABOVE M Last Name First Name MI Suffix JR SR a E E Street Address Apt Suite Use this Address 2 v O v E for this order only 1 a City State ZIP Code a Daytime Phone Evening Phone z REFILL INFORMATION To order mail service refills enter your prescription number
6. alud con contratos con ambos Medicare y Medicaid de Ohio para proporcionar los beneficios de ambos programas a las personas inscritas Esta informaci n est disponible en otros formatos que incluyen Braille letra grande y audio You can get this information for free in other languages Call 855 665 4623 The call is free Usted puede recibir esta informaci n en otros idiomas gratuitamente Llame al 855 665 4623 Esta es una llamada gratuita Pueden aplicarse limitaciones copagos y restricciones Para m s informaci n llame al Departamento de Servicios para Miembros del Plan Molina Dual Options MyCare Ohio Medicare Medicaid o consulte el manual del miembro del Plan Molina Dual Options MyCare Ohio Medicare Medicaid Los beneficios lista de medicamentos cubiertos red de farmacias y proveedores o copagos pueden cambiar de vez en cuando durante el a o y el 1 de enero de cada a o MAIL SERVICE CAREM K ORDER FORM 2 Mail order form to y y bs A A A A A A AA CVS CAREMARK MTP STD y PO BOX 94467 y PALATINE IL 60094 4467 3 a Enter ID
7. ctor s Phone ALLERGY HEALTH INFORMATION COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED Allergies Q None Q Aspirin Cephalosporin Codeine Erythromycin Peanuts Q Penicillin Q Sulfa Q Other Conditions O Arthritis O Asthma O Diabetes O Acid Reflux O Glaucoma Q Heart Problem O High Blood Pressure High Cholesterol O Migraine O Osteoporosis Prostate Issues Thyroid O Other fo A A wu Special Instructions E aA A PAYMENT INFORMATION Select one payment method below Q Electronic Check Processing Please pre register at Caremark com or call Customer Care dot O Bill Me Later Subject to credit approval Please pre register at Caremark com or call Customer Care O Credit Debit Card VISA MasterCard Discover or American Express O Charge most recently used credit card O Charge new updated credit debit card provide info below Exp Date O Check Money Order Amount Credit Card Holder Signature Date REGULAR DELIVERY IS FREE Make check or money order payable to CVS Caremark and Allow up to 10 days for delivery write your ID on the check money order Returned checks Fill in oval for faster delivery will be subject to a fee of up to 40 depending on state O 2nd Business Day 17 per order law The selected payment method unless paying by check will be charged for future orders
8. e register at Caremark com or call Customer Care a O Please fold here Please fold here tae O Bill Me Later Subject to credit approval Please pre register at Caremark com or call Customer Care O Credit Debit Card VISA MasterCard Discover or American Express O Charge most recently used credit card O Charge new updated credit debit card provide info below Exp Date f O Check Money Order Amount Credit Card Holder Signature Date REGULAR DELIVERY IS FREE Make check or money order payable to CVS Caremark and Allow up to 10 days for delivery write your ID on the check money order Returned checks Fill in oval for faster delivery will be subject to a fee of up to 40 depending on state 0 2nd Business Day 17 per order law The selected payment method unless paying by check will be charged for future orders unless a different form of payment is provided It will also be charged for any outstanding balance due O Fill in oval if you DO NOT want the selected payment method to be automatically charged for future orders N MTP MOF 1208 32657MED0713 O Next Business Day 23 per order Charges subject to change Faster delivery options only affect shipping time not processing time and a only be sent toa street address not a P O box WT MAIL SER
9. o Para nuevas rdenes no se le olvide incluir su receta m dica Puede pagar usando un cheque electr nico Bill Me Later o una tarjeta de cr dito O puede pagar con un cheque o giro postal No env e dinero en efectivo e Opci n 2 Pagina web Visite www caremark com e inicie sesi n o inscribase haciendo clic en Start a o New Prescription y luego haga clic en FastStart e Opci n 3 Tel fono Llame al n mero de tel fono gratuito de FastStart al 888 277 4144 de lunes a viernes de 9 a m a 9 p m horario de la zona central Usuarios de TTY TDD llamen al 800 231 4403 Proporcione su n mero de identificaci n del Plan Molina Dual Options MyCare Ohio Medicare Medicaid se encuentra en su tarjeta de identificaci n los nombres de sus medicamentos el nombre y n mero de tel fono de su m dico y su direcci n postal Tambi n existe un n mero de tel fono gratuito automatizado para ordenar sus renovaciones 24 horas al d a los siete d as de la semana 45368MMP0914 NSR_15_MMP_208_OHMailorderSp e Opci n 4 Doctor Proporcione el n mero de tel fono gratuito del m dico de FastStart al consultorio de su m dico 888 277 4144 TTY TDD 800 231 4403 y solic tele a su m dico que lo llame le env e un fax o le haga una receta de forma electr nica Para acelerar el proceso su m dico necesitar su n mero de identificaci n del Plan Molina Dual Options MyCare Ohio Medicare Medicaid se
10. of Birth Your E Mail Date new prescription written Doctor s Last Name Doctor s First Name Doctor s Phone ALLERGY HEALTH INFORMATION COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED Allergies Q None Q Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin Q Sulfa O Other Conditions O Arthritis O Asthma O Diabetes O Acid Reflux O Glaucoma Heart Problem O High Blood Pressure High Cholesterol O Migraine Osteoporosis Prostate Issues Thyroid O Other 2nd PERSON ORDERING A PRESCRIPTION e ep ncaos 0 Panta Spanish Suffix JR SR lt Please fold here Please fold here Gender O M QF Date of Birth Your E Mail Date new prescription written Doctor s Last Name Doctor s First Name Doctor s Phone ALLERGY HEALTH INFORMATION COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED Allergies Q None Q Aspirin Cephalosporin Codeine Erythromycin Peanuts Q Penicillin Q Sulfa Q Other Conditions O Arthritis O Asthma O Diabetes O Acid Reflux O Glaucoma Q Heart Problem O High Blood Pressure High Cholesterol Migraine Osteoporosis Q Prostate Issues Thyroid O Other Special Instructions PAYMENT INFORMATION Select one payment method below Q Electronic Check Processing Please pr
11. s here 1 YB A 5 G7 8 Prescriptions sent in one envelope may be shipped together unless you request otherwise 32657MED0713 2008 Caremark All rights reserved P12 N FILL IN FOR UP TO TWO PEOPLE WHO WILL RECEIVE PRESCRIPTIONS WITH THIS ORDER 1st PERSON ORDERING A PRESCRIPTION 0 Easy open caps O Print in Spanish Suffix JR SR Gender Q M QF Date of Birth Your E Mail Date new prescription written Doctor s Last Name Doctor s First Name Doctor s Phone g ALLERGY HEALTH INFORMATION COMPLETE ONLY IF CHANGED OR NOT PREVIOUSLY REPORTED Allergies Q None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin 2 Q Sulfa Q Other 2 a Conditions O Arthritis O Asthma O Diabetes O Acid Reflux O Glaucoma O Heart Problem 2 O High Blood Pressure High Cholesterol O Migraine Osteoporosis Q Prostate Issues Thyroid O Other 2nd PERSON ORDERING A PRESCRIPTION a Ma Suffix JR SR Gender Q M QF Date of Birth Your E Mail Date new prescription written Doctor s Last Name Doctor s First Name Do
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