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 LogoDMC 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.


  MasterCard       Visa      

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