. Spanish forms and labels Allergies: Special instructions: Credit or debit card. (VISA , MasterCard , Discover , or American Express ) Check or money order. Amount: $ C D E Spanish forms and labels Erythromycin Cephalosporin Codeine Aspirin None Sulfa Other: Peanuts Arthritis Asthma Diabetes Acid reflux Glaucoma High blood pressure Other: High cholesterol Migraine Osteoporosis Prostate issues Penicillin Heart problem Thyroid Date new prescription written: Doctors last name Doctors first name Doctors phone # Allergies: Erythromycin Cephalosporin Codeine Aspirin None Sulfa Other: Peanuts Arthritis Asthma Diabetes Acid reflux Glaucoma High blood pressure Other: High cholesterol Migraine Osteoporosis Prostate issues Penicillin Heart problem Thyroid Date new prescription written: Doctors last name Doctors first name Doctors phone # Fill in this oval if you DO NOT want us to use this payment method for future orders. 2nd business day ($17) Next business day ($23) Credit card holder signature/Date Suffix (JR,SR) Suffix (JR,SR) Date of birth: Last Name Nickname Nickname First Name MI Last Name First Name MI Date of birth: MM-DD-YYYY MM-DD-YYYY MMYY Exp.Date Tell us about new health information for 1st person if never provided or if changed. Medical conditions: Tell us about new health information for 2nd person if never provided or if changed. Medical conditions: Electronic check. Pay from your bank account. (You must first register online or call Customer Care.) How would you like to pay for this order? (If your copay is $0, you do not need to provide payment information.) E-mail address: E-mail address: Tell us about the people ordering prescriptions. If there are more than two people, please complete another form. First person with a refill or new prescription. Use your card on file. Use a new card or update your cards expiration date. Second person with a refill or new prescription. Regular delivery is free and takes up to 5 days after your order is processed. If you want faster delivery, choose: Faster delivery can only be sent to a street address, not a PO Box Expected processing time from receipt of this form: Refills: 1-2 days New/renewed prescriptions: Within 5 days unless additional information is needed from your doctor (Charges subject to change) MOF WEB 0122 BCBSMA Make check or money order payable to CVS Caremark. :ULWH\RXUSUHVFULSWLRQEHQHW,'QXPEHURQ\RXU check or money order. If your check is returned, we will charge you up to $40. Payment for Balance Due and Future Orders: If you choose electronic check or a credit or debit card, we will use it to pay for any balance due and for future orders unless you provide another form of payment.