PBM Plus: Mail Service Prescription Online Refill Order Form

Online Refills

Patient Information: Please complete the following information for each order

Patient's Name:*


First*	M.I.	Last*

Date Of Birth*
//
MM / DD / YYYY*

Gender:* M F

Select if this is a permanent change of address Select if this is a temporary address for this order only

Patient's Mailing Address:*

Street*	Apt #

City*	State*	Zip Code*

Phone Number*
( ) - -

Email address:

Please check this box if you do not want child-proof caps.
(By requesting easy open caps, I acknowledge and agree to release Advantage Health Services, Inc., PBM Plus, Inc. and the PBM Plus Mail Service Pharmacy, LLC from any and all obligations and liabilities related to not providing child resistant packaging under the Poison Prevention Act.)

II. Payment Information: Please indicate how you will be paying for this order. We must have payment information.

Select this button if your payment information is already in our system

Select this button if you need to add or change credit card information (we will contact you)

In order to process your refill request, we will need your credit card information. If that information is on file, we will process your prescription(s) on the next business day. If the information is not on file we will contact you to get the information. Please be sure that the phone number entered above is a daytime phone number where we can reach you. To protect your privacy we do not accept credit card information over the Internet.

III. Insurance Information: If your prescription is covered by a pharmacy benefit plan, please complete this section


Member ID No*	Plan Sponsor (employer or health plan)*	Group Number*

All of the above information is found on your ID card.

IV. Refill Prescription Information*
Please list the prescription number(s) and the name of the medication you are ordering in the spaces below. The name of the medication can be found on your bottle label.

Rx#:	Medication Name:
Rx#:	Medication Name:
Rx#:	Medication Name:
Rx#:	Medication Name:

Any additional comments:

Required fields are indicated with a red * and bolded.