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To open and print the following PDF forms you’ll need Adobe® Acrobat® Reader. You may also request forms by calling Member Services at the number listed on the back of your member card.

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Prescription Medication Mail Order Forms

You can use the forms listed below (in PDF format) to order your prescriptions.

If you’d like prescriptions faxed to Walgreens Mail Service, simply print the above forms and bring them to your doctor. Doctors can then fax a completed form to Walgreens Mail Service. If you can’t make an appointment with your doctor, follow these steps to get your prescription:

  1. Complete the Member, Patient and Payment Information sections. A credit card number is required at the time the form is submitted.
  2. Have your doctor supply the prescription information requested using the prescriber's form.
  3. Have the doctor fax the form.

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Prescription Medication Claim Forms

You can use the following claim form if you:

  • Forgot to present your member card to the pharmacist when you purchased your medication and you need reimbursement.
  • Need to submit for reimbursement subject to the coverage provisions of your plan.

Simply attach your original prescription receipts to your completed form and mail to the address indicated. You may want to make copies of your original receipts as we’re unable to return them to you.

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Authorization for Use and Disclosure of Protected Health Information

Authorization for a member's health care providers to disclose health information to a designated party for a specific purpose.