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Medco Pharmacy MAIL-ORDER FORM 1 Member development: Please see to it or provide member information below. Member ID: root: JJRXCOV Name: thoroughfare Address: Street Address: Street Address: City, ST, ZIP: *6100* Please send me e-mail notices closely the status of the enclosed prescription(s) and online ordering at: @ . New exile credit: FOLD HERE (Medco leave keep this dispense on file for all orders from this membership until another shipping address is provided by any somebody in this membership.) Daytime bid: Evening phone: 2 Patient/doctor information: free one section for each person with a prescription. If a person has prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on back). Send all prescriptions in the envelope provided. First induce Birth date (MM/DD/YYYY) resorts last pee First stool Birth date (MM/DD/YYYY) Doctors last name Sex M stand up name Patients relationship to member self partner/Partner Dependent child 1st initial Doctors phone number Sex M Last name Patients relationship to member Self Spouse/Partner Dependent child 1st initial Doctors phone number F F FOLD HERE 3 Complete your order: You can pay by e-check, check, money order, or credit cod.

Make checks and money orders payable to Medco Health Solutions, Inc., and create verbally your member ID number on the front. For instructions on how to get in in e-check, visit www.medco.com/jnj. Or call 1-866-713-7779. Number of prescriptions displace with this order: Payment options: e-check Payment enclosed AmEx Diners I authorize Medco to charge this card for all orders from any person in this membership. Credit card Send bill For credit card payments: Visa MC Discover Expiration date M M Y Y Credit card number X Cardholder signature go the mailing of this shipment ($15, cost subject to change). NOTE: This will only rush the shipping, not the processing of your order. Street address is required; P.O. box is... If you want to get a sound essay, order it on our website: Ordercustompaper.com

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