120502_testpatientprofileform

Drug Allergy Conditions
Family Member 3
Family Member 2
Family Member 1
Beneficiary
medications, and drug allergies Please list other health conditions, bottom of this chart. appropriate box. If an allergy has occurred with a medication not listed below, please list it in the space provided at the INSTRUCTIONS FOR COMPLETING THE DRUG ALLERGY CONDITIONS:
Physician Last Name (If Known)
Birth Date
Family Member 3 First Name
FAMILY MEMBER 3 IDENTIFICATION NUMBER
Physician Last Name (If Known)
Birth Date
Family Member 2 First Name
FAMILY MEMBER 2 IDENTIFICATION NUMBER
Physician Last Name (If Known)
Birth Date
Family Member 1 First Name
FAMILY MEMBER 1 IDENTIFICATION NUMBER
Physician Last Name (If Known)
Birth Date
Beneficiary First Name
SPONSOR IDENTIFICATION NUMBER
1. PERSONAL INFORMATION
Ibuprofen, Naproxen, Celebrex®, Others) Aspirin and non-steroidal pain relievers (Vioxx, Cefzil, Others) Cephalosporins (K Penicillins (Ampicillin, Amoxicillin, Others) and Beneficiary
MAIL ORDER REGISTRATION
Family Member 1
Physician Phone # (If Known)
Physician Phone # (If Known)
Physician Phone # (If Known)
Physician Phone # (If Known)
Last Name
Last Name
Last Name
Last Name
Family Member 2
Family Member 3
FOLD HERE
FOLD HERE
DD02-1295IMG
NO POSTAGE
NECESSARY IF
MAILED IN THE
UNITED STATES
BUSINESS REPLY MAIL
FIRST-CLASS MAIL PERMIT NO. 14262 PHOENIX AZ
2. SHIPPING INFORMATION
NOTE: You must provide a U.S. postal address. Prescriptions
cannot be mailed to private foreign addresses.
First Name
Middle Initial
Last Name
(U.S. Postal
Address,
including
APO/FPO)
City
ZIP or Postal Code
FOLD HERE Phone #
3. PAYMENT INFORMATION
Standard delivery of your order is FREE. Your order will arrive within
14 days from the date we receive your order.
To expedite shipping, you may choose to have your order sent by next-day delivery, after it is processed, for an additional charge. (NOTE: This will only affect shipping time, not the processing of your order.)
Please include payment with your order. DO NOT SEND CASH. To calculate your payment, please refer to your
Beneficiary Guide for your copayment. Add $18 if you want next-day delivery.
Check/Money Order
Amount Enclosed $
Credit Card #
Expiration Date M M - Y Y
Credit Card #
Expiration Date M M - Y Y
NOTE: All future orders will be charged to this credit card, unless payment (check) accompanies the order.
Cardholder
AUTHORIZED SIGNATURE
Please print name as it appears on credit card As required by the U.S. Department of Defense, we will dispense FDA-approved generic medications
FOLD HERE
unless your physician establishes that the brand-name medication is medically necessary.
4. SIGNATURE INFORMATION
IF APPLICABLE, PLEASE SIGN THE FOLLOWING STATEMENTS:
I request that this and future orders be shipped I would like my prescriptions dispensed with “Signature Required”. I understand there will NON-CHILD resistant caps.
be an additional charge for this service.
AUTHORIZED SIGNATURE
AUTHORIZED SIGNATURE
REVIEW YOUR PRESCRIPTION
INSTRUCTIONS FOR COMPLETING THIS FORM
• Check to see if the patient name is clearly written
• Complete all portions of this form by printing in ALL
on the prescription. If not, print the patient’s full name,
CAPITAL LETTERS using BLACK INK.
address and phone number on the back of the prescription.
• Make sure you have completed the Drug Allergy
• Check to see if the physician’s signature is legible.
Conditions section. This enables our pharmacists to If not, please circle the physician’s preprinted name on the review your patient record prior to filling prescriptions.
prescription, or print the name of the physician on the back • Fold the completed form and place it along with your prescriptions in the pre-addressed envelope provided.
• Check to see if the physician’s phone number is printed
• Include your check or money order (if not paying with a on the prescription. If not, print the physician’s phone
number, including area code, on the back of the prescription.
HEARING IMPAIRED: 877.540.6261
• If there are more than 3 Family Members, write
FOR REFILLS: www.express-scripts.com
the information on a separate piece of paper.
Toll-Free: 866.DOD.TMOP (866.363.8667)

Source: http://www.fhinc.net/tricare/Archive/SampleStandardDODMailOrderForm.pdf