Forms

 

Locate and fill-out the form you need from the list below.


Mail Service Order Form    (Español)
This form should accompany your prescription orders. You can print and mail this form in along with your new prescription. If you choose to fax in the form, your physician must phone or fax in your prescription(s).

Protected Health Information Authorization
Authorization for WellDyneRx to provide access to Members Protected Health Information (PHI) to another Individual

Mail Order Prescription History Request
This form should be used by the member or his/her Personal Representative to request printouts of the member’s prescription history.

 

Forms

 

Locate and fill-out the form you need from the list below.


Mail Service Order Form    (Español)
This form should accompany your prescription orders. You can print and mail this form in along with your new prescription. If you choose to fax in the form, your physician must phone or fax in your prescription(s).

Protected Health Information Authorization
Authorization for WellDyneRx to provide access to Members Protected Health Information (PHI) to another Individual

Mail Order Prescription History Request
This form should be used by the member or his/her Personal Representative to request printouts of the member’s prescription history.



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