Optum New home delivery prescription order form

New home delivery prescription order form

1. Member and physician information — please use black or blue ink. One form per member.

Member ID number

(Additional coverage, if applicable) Secondary member ID number

Last name First name MI

Delivery address Apt. #

City State Zip code

Phone number with area code

Date of birth (mm/dd/yyyy) Email address

Physician name

Physician phone number with area code

2. Health history

Medication allergies:  Aspirin  Erythromycin  Quinolones  Others:__________________

 None known  Cephalosporins  NSAIDs  Sulfa _____________________________

 Amoxil/Ampicillin  Codeine  Penicillin  Tetracyclines _____________________________

Health conditions::  Asthma  Glaucoma  High cholesterol  Others:__________________

 None known  Cancer  Heart condition  Osteoporosis _____________________________

 Arthritis  Diabetes  High blood pressure  Thyroid disease _____________________________

Over-the-counter medications, vitamins and herbal supplements taken regularly:

3. Payment and shipping information — do not send cash

Standard delivery is included at no charge. Prescriptions should arrive within 5 business days after the pharmacy receives the

complete order. The pharmacy will contact you if there will be an extended delay in delivering your medications.

Visit the website listed on your member ID card to check drug pricing before sending payment. Once shipped, medications

may not be returned for a refund or adjustment.

 Expedite shipping. Add $20.00 to order

amount (subject to change).

 Check enclosed. All checks must be

signed and made payable to: Optum.

 Charge to my credit card on file.

 Charge to my new credit card.

New credit card number

Expiration Date (Month/Year) Visa, MasterCard, AMEX

and Discover are accepted.

Signature: ___________________________________________________________________________________ Date: ______________________

For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such

expenses related to prescription orders. By supplying my credit card number, I authorize Optum to maintain my credit card

on file as payment method for any future charges. To modify payment selection, contact customer service at any time.

4. Mail this completed order form with your new prescription(s) to Optum, P.O. Box 2975,

Mission, KS 66201. Do not staple or tape prescriptions to the order form.

WF11288810_230810 5633-062022 NRX001