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CVS.COM /1/866//1/ EACH WEEK. OR CALL CVS AT FOR UPDATES. Include a current PHYSICIAN'S PRESCRIPTION CARD for each patient's name, address, EMAIL ADDRESS, PHONE NUMBER AND DOSE NUMBER. No refills from pharmacy or office. Do NOT leave this form out of the mail because it carries a risk that your prescription may expire before delivery. You will be charged 25 for each refilled prescription and 0 for each expired prescription. Prescription must be in by Monday, December 31. No prescriptions will be returned. We reserve your pharmacy records to help meet these delivery requirements. No Exceptions Filing and processing online form online with PharmacyRecorder.com for a 25 fee. , option 2 or 3. Must be 18 years of age or older to qualify. Prescription Refills Mail your prescription refills with this form. No Refills from MA, office, and pharmacy. No refills from pharmacy. Do NOT leave this form out of the mail because it carries a risk that your prescription may expire before delivery. You will be charged 25 for each refilled prescription and 0 for each expired prescription. We reserve your pharmacy records to help meet these delivery requirements. No Exceptions Filing and processing online form online for a 25 fee. , option 2 or 3. Must be 18 years of age or older to qualify. Prescription Service and Medication Administration Mail this form to your pharmacy. Include your: Name of Physician (Doctors, Dental Attorneys, etc.) Type of Prescribed Medication (A.D.A.P.C., MA or MATCH) and Medication ID Number (Patient Medication Record number). Pharmacist/Order Desk (P.M. or O.M.) Name of your Prescription Service Provider including your street address and P.M. or O.M. address when not P.M. or O.M. (in state names only) Name/Pharmacy Name (if different from your P.M./O.M.) If prescription was mailed to you, mail this form to the patient.

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