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Getting Started Ordering By Mail
Refills Are Even Easier
It’s simple to order refills or to find out how many
refills you have left. You can do this by mail, over the Internet at www.4dpharmacy.com/rxsolutions or by
prescription(s). For identification accuracy, please phone by calling 1.888.225.2610 (TTY: 1.800.498.5428).
write your date of birth on each prescription. Just Refills are usually processed within 48 hours, and follow these step-by-step instructions to begin you can order three weeks before your medication taking advantage of Prescription Solutions Mail 1. For current medications: Have your doctor
send you a new prescription for your current Call Or Go Online To Find Out More
maintenance medications. Be sure your doctor We know there are times you’ll need to talk to a prescribes a 90-day supply, plus three refills.
pharmacist about your prescriptions, so we havea licensed pharmacist on call 24 hours a day, 7 days 2. For new medications: Have your doctor write
two prescriptions: one for a 30-day supply andone for a 90-day supply plus three refills. Fill To learn more about Prescription Solutions Mail the 30-day prescription at your local pharmacy.
Service Pharmacy in general or to speak to a Then once you and your doctor are confident pharmacist, call our Customer Service department you’ll continue on this new medication, follow at 1.888.225.2610 (TTY: 1.800.498.5428), 24 hoursa day, 7 days a week.
3. Mail your doctor’s original prescription,
for information about the mail service pharmacy as along with payment, in the attached
well as to order refilled prescriptions.
envelope. Be sure to include the confidential
patient profile questionnaire also attached.
Your prescription should arrive in about 7 working For copayment amounts, drug coverage information, days from the day your order is received. Included or general plan questions, please call 4D at with your medication will be a reorder form, 1.877.647.4026
detailed instructions that tell you how to takethe medication, possible side effects and otherinformation. If you’d like to consult with one of our Please mail your completed
pharmacists regarding any questions or concerns, Mail Service Pharmacy order form to:
please call our Customer Service department at Prescription Solutions
1.888.225.2610 (TTY: 1.800.498.5428), 24 hours P.O. Box 2975
Shawnee Mission
KS 66201-1375
2008 Prescription Solutions. This document is proprietary to Prescription Solutions and is subject to federalcopyright protection. Any unauthorized reproduction, dissemination or use of this document is strictly prohibited.
Prescription Solutions Mail Service Pharmacy Order Form
Please be sure to include this order form and your original prescription(s). Please print in black or blue ink.
Health History
Please complete if not reported previously or a change has occurred.
Allergies:
No Known Sulfonamides/Sulfa Penicillin Erythromycin Codeine Health Conditions:
Please list any Over The Counter or Herbal Medications you take regularly:
Special Instructions
In order to provide you with high quality medications at the best possible price, we substitute FDA-approved generic
equivalents for brand name medications whenever possible. Generic medications will not be sent if your doctor indicates
a brand name medication should be dispensed. If you require a brand name medication for this order, please
check the box below and list all medication names*:

*Brand name medications may be subject to a higher cost.
Standard shipping of your order is free and most are shipped by the U.S. Postal Payment & Shipping Information
Service. Please note, the shipment method will not expedite processing time. Ifyou require a faster shipping method for this order, please indicate below.
Do Not Send Cash
Use credit card on file
Overnight Shipment Method - Add $12.50 to order amount
Use enclosed check for payment
All checks must be signed and made payable to Prescription Solutions Use credit card for payment: (Visa, MasterCard, Discover, American Express)
Credit Card Number:
This credit card will be billed for medicine costs, expedited shipping (if applicable), and any outstanding balances. Itwill also be billed for all future orders, unless you provide a different form of payment. Payment in excess of amountsdue will be applied to your account. If method of payment is not indicated, Prescription Solutions will apply thecharges to the credit card on file.
Please mail your completed Mail Service Pharmacy order form to:
Prescription Solutions P.O. Box 2975 Shawnee Mission, KS 66201-1375

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