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ProCare PharmacyCa To ensure fast delivery, please verify your prescriptions before you leave the physician’s office to make certain that: • The physician’s name is legible. • The patient’s name is legible. • The exact daily dosage is specified. • The exact strength is specified. • A 90-day supply quantity is indicated. • The number of refills will last for 1 year. Refill by Phone Call our Refill by Phone Interactive Voice Center at: [PHONE REDACTED] using a touch tone phone. Please have the prescription number, which is located on the prescription bottle, available when calling. Refills by Internet To refill prescription(s) online, simply complete the Refill Request Form that is located at www.procarerx.com. Choose the ‘Mail Order Refills’ option listed on the left-hand side of the page under the Quick Links panel. Refill by Mail • Complete all sections on the reverse side. • Enclose payment amount (if applicable). • Mail your request using the enclosed envelope to: ProCare PharmacyCare 2650 SW 145th Avenue Miramar, FL 33027 Customer Care Center: [PHONE REDACTED] Fax: [PHONE REDACTED] TTY Line: 711 Monday through Friday 8:00 am to 6:00 pm (ET) Saturday 9:00 am to 1:00 pm (ET) [EMAIL REDACTED] ProCare PharmacyCare Miramar, FL HST Pharmacy Gainesville, GA Prescription Order Form and Patient Profile for New Members [PHONE REDACTED] TTY Line: 711 [EMAIL REDACTED] ---PAGE BREAK--- Enjoy These Benefits A 90-day supply of your medication may be available at a lower copay than you would pay at your retail pharmacy. Refilling your prescription is easy when using the following options: Website: www.ProCareRx.com (Click on ‘Mail Order Refills’ under the Quick Links panel) For faster service on a new prescription, ask your physician to call [PHONE REDACTED] or fax to [PHONE REDACTED] Patient Profile and Order Form Instructions for new members: first time users of ProCare PharmacyCare’s Home Delivery program must complete all sections of this form. Member Date of Male Female Apt. State: Home Cell Best time to call:_____ Alternative Email By providing your email address you are granting ProCare Rx permission to contact you via email regarding your prescription drug coverage. All prescriptions are screened for potential Allergies: □ None □ Penicillin □ □ Sulfa □ Aspirin □ Other interactions and allergy sensitivity based on the Health Conditions: □ Asthma □ Cholesterol □ Depression □ Diabetes □ Heart Failure information you provide in your patient profile. □ Thyroid □ Stomach Ulcer/Reflux □ High Blood Pressure □ Order Form for New Participants: Prescriptions are for: □ Member □ Spouse □ Dependent Member Please write the Member ID, Date of Birth, and your address on the back of each prescription. □ Check here if you would like non-childproof caps with your order. (Childproof caps are used on all prescription orders for safety during shipping.) Payment Method □ Check (See invoice for payment information) □ Money Order □ Visa □ MasterCard Name (as it appears on card): If diabetic, indicate brand used for diabetic supplies: Lancets: Test strips: Spouse Date of Male Female Allergies: □ None □ Penicillin □ □ Sulfa □ Aspirin □ Other Health Conditions: □ Asthma □ Cholesterol □ Depression □ Diabetes □ Heart Failure □ Thyroid □ Stomach Ulcer/Reflux □ High Blood Pressure □ If diabetic, indicate brand used for diabetic supplies: Lancets: Test strips: Dependent Date of Male Female Allergies: □ None □ Penicillin □ □ Sulfa □ Aspirin □ Other Health Conditions: □ Asthma □ Cholesterol □ Depression □ Diabetes □ Heart Failure □ Thyroid □ Stomach Ulcer/Reflux □ High Blood Pressure □ If diabetic, indicate brand used for diabetic supplies: Lancets: Test strips: Account CERTIFICATION PLEASE READ AND SIGN: I CERTIFY THAT THE INFORMATION PROVIDED IN THIS FORM IS CORRECT, AND I AUTHORIZE THE RELEASE OF ALL INFORMATION TO THE HEALTH INSURANCE PLAN, ADMINISTRATOR, OR UNDERWRITER. AUTHORIZE PROCARE PHARMACYCARE, LLC OR HST PHARMACY TO SUBSTITUTE GENERIC DRUGS IN ALL CASES WHEN Expiration date: Date: LEGALLY PERMISSIBLE IN ACCORDANCE WITH APPLICABLE LAW, AND CONSISTENT WITH THE DOCTOR’S ORDERS. □ Check here if you do not want future orders charged to this credit card which will be placed on file. Signature Date I SIGN SIGN