PRESCRIPTION DRUG MAIL ORDER FORM

EASY ORDERING INSTRUCTIONS:

1. Complete the handy order form. PLEASE PRINT. The name and address portion of the order form will be used in preparing your shipping label. Please be sure to indicate your day- time phone number in case we must contact you.

2. Enclose the Original Prescription completed by your doctor. Copies cannot be filled. Be sure the doctor's name, address and phone are legible.

3. Refills on prescriptions- make sure your doctor indicates the number of refills authorized. When ordering refills use the prescription number on the label from CFI Pharmacy.

Member's Name: ______________________________________________                                                        1-800-233-7139

Member's Social Security No._________-__________-______________                                           Information for Return Shipping Label

Sponsors No. (From NPA Rx Card) ____________________________                            To: _____________________________________________

Home Phone: (________) _________ - ___________________                                             ______________________________________________

Work Phone: (________) _________ - ____________________                                            ______________________________________________

Doctors Name:_______________________________________                                      (___) Check here if you want a "Safety Cap" container.

Doctors Phone: (_______) _________ - ___________________                                     Remember to enclose the deductible payment for each

The law permits pharmacists to substitute a less expensive generically                      prescription, if applicable, MAKE CHECKS PAYABLE TO CFI.

equivalent drug for a brand name drug, unless you or your physician direct Credit Card #: ___________________________________________

otherwise. Your Prescription will be filled generically unless you direct otherwise. Type of Card: ________________________ Exp. Date:__________

Signed: ____________________________________________________________ (____) CHECK HERE IF YOU DO NOT WANT A GENERIC.

INSERT REFILL SLIP OR FILL OUT THIS SECTION __ FOR NEW PRESCRIPTIONS (USE SEPERATE PIECE OF PAPER IF NECESSARY)

No. of Rx's             Patients Name*                                 Relationship              Birth date    Please describe below any allergies, chronic  Enclosed                                                                                         disease or drug sensitivities you have. 

1. _______ _____________________________________________   (__) Member______________________________________________________ 

2. _______ _____________________________________________ (__) Spouse ______________________________________________________

3. _______ _____________________________________________ (__) Child _______________________________________________________

THIS SECTION ---- FOR REFILL PRECSRIPTIONS (USE SEPERATE PIECE OF PAPER IF NECESSARY)

Rx Number                          Patient Name*                                          Doctors Name                                       Drug Name

1. ________________________________________________________________________________________________________________________

2. ________________________________________________________________________________________________________________________

* Indicates Last Names, if they are not the same as the subscriber.

PLEASE DO NOT WRITE IN THIS AREA

PLEASE MAIL THIS FORM TO ADDRESS BELOW:

CFI

4415 LEWIS ROAD, P.O. Box 69301

Harrisburg, Pa. 17106-9301