DMC Pharmacy Mail Service
 

Please include any new prescription(s) along with this form.

Mail To:

DMC Pharmacy Mail Service
PO BOX 2836
DETROIT  MI  48202-0836

Please print all information (Missing or incorrect information may cause delay or the inability to process your order).

New Prescriptions; please include a copy of the front and back of your insurance card for proper processing.

Please submit refill request 10-14 days prior to depletion of medication to allow time for processing and delivery.

DMC Pharmacy Mail Service is available Monday through Friday.
All Prescriptions received before 10:00am will be mailed, in most cases, the same day.
All Prescriptions received after 10:00am will be mailed, in most cases, within 1 to 3 days.

IF YOU NEED THIS MEDICATION WITHIN 24-36 HOURS, YOU SHOULD CONSIDER HAVING YOUR PRESCRIPTION FILLED AT A
DMC ON-SITE PHARMACY LOCATION.

NOTE: All controlled substance prescriptions will be mailed separately and will require a signature at the time of delivery.

DMC Pharmacy Mail Service
Phone:  313-966-2436

                                                                                                

Patient Information	Insurance Information
Patient First Name: ___________________ Patient Last Name: ___________________ Patient Date of Birth: ____/____/_______ (MM/DD/YYYY) Gender (circle one):   Male   Female Drug Allergies (circle one):   Yes   No If Yes, List Drug Allergies: __________________________________________	Subscriber / Employee ID#: ____________ Group Code: ____________                                     Insurance Plan:  ____________                                  Relationship to Subscriber (circle one):      Self        Spouse        Dependent
Address to Mail Prescription	Payment Information
(NO PO Box) Address:__________________________________ City, State Zip:______________________________ Country:________________ Email:______________________________                      Daytime Phone: (for error/question reporting only) _______________________                               NOTE:  All controlled substance prescriptions will be mailed separately and will require a signature at the time of delivery.	Card Number: _______-_______-_______-________ Card Security Code : _______ The card security code (csc) is usually a 3 or 4 digit number, which is not part of the credit card number. The csc is typically printed on the back of a credit card (usually in the signature field). Card Expiration Date: Month: ______ Year ______ Name as it appears on card: _____________________
Please check all that apply: all that apply:   New Prescription Please include original prescription when mailing this form.   Refill Prescription Please print your prescription number(s) (Located on the labels of your Rx bottle) and check the box to the right if the prescription is being transferred from a non-DMC pharmacy.    1______________   2______________    3______________    4______________   5______________   6______________    7______________    8______________ Transfer Pharmacy Information Please provide names, phone numbers and addresses for the pharmacy where any of the transfer prescriptions you listed were last filled. _______________________________________________________________________________ _______________________________________________________________________________ Comments to Pharmacist _______________________________________________________________________________ _______________________________________________________________________________  Mail form to: DMC Pharmacy Mail Service, PO BOX 2836, DETROIT MI  48202-0836