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Catamaran Home Delivery 1 Member information: Please verify or provide member information below.
Please send me e-mail notices about the status of the enclosed Member ID:
prescription(s) and online ordering at: New Shipping Address: Catamaran Home Delivery will keep this address on file for all orders from
City, State, Zip: membership until another shipping address is provided by any person in this *A physical address (not a P.O. Box) is typically required for temprature-sensitive medications and controlled substances.
2 Patient/doctor information: Complete one section for each person with a prescription. If a person has
prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on back). Send all prescriptions in the envelope provided.
Birth date (MM/DD/YYYY) Patient's relationship to member Doctor's last name 1st initial Doctor's phone number Birth date (MM/DD/YYYY) Patient's relationship to member Doctor's last name 1st initial Doctor's phone number 3 Complete your order: You can pay by check, money order, or credit card. Make checks and money
orders payable to Catamaran Home Delivery, and write your member ID number on the front. You can price
medications at www.mycatamaranrx.com, or call the telephone number listed on your ID card.
Number of prescriptions sent with this order:
Payment options:
Payment enclosed For credit card payments:
Credit card number I authorize Catamaran Home Delivery to charge
this card for any person for all orders from in this Cardholder signature Shipping Methods: Normal (no charge) 2nd Day Air ($11.00) Next Day Air ($25.00) Mailing instructions are provided on the next page.
Patient/doctor information continued
Birth date (MM/DD/YYYY) Patient's relationship to member Doctor's last name 1st initial Doctor's phone number Birth date (MM/DD/YYYY) Patient's relationship to member Doctor's last name Doctor's phone number FOLD HERE Important reminders and other information
Check that your doctor has prescribed the maximum days'
Catamaran Home Delivery will make all possible efforts,
supply allowed by your plan (not a 30-day supply), plus refills as appropriate by law, to substitute generic
for up to 1 year, if appropriate. Also, ask your doctor or formulations of medication, unless you or your doctor
pharmacist about safe, effective, and less expensive generic specifically directs otherwise.
Texas laws permit pharmacists to substitute a less Complete the Health, Allergy & Medication Questionnaire.
expensive generic equivalent for a brand-name drug unless you There may be a limit to the balance that you can carry on
or your doctor directs otherwise. Check the box if you do not
your account. If this order takes you over the limit, you must wish a less expensive brand or generic drug.
include payment. Avoid delays in processing by using a credit Please note that this applies only to new prescriptions and to any refills of that prescription. If you are a Medicare Part B beneficiary AND have private
For additional information or help, visit us at
health insurance, check your prescription drug benefit
www.mycatamaranrx.com or call Member Services at the
materials to determine the best way to get Medicare Part B telephone number listed on your ID card. Member Services is drugs and supplies. Or, call Member Services at the telephone available 24/7. TTY/TDD users should call 1 866 830-3726. number listed on your ID card. To verify Medicare Part B prescription coverage, call Medicare at 1 800 MEDICARE (1 Federal law prohibits the return of dispensed controlled substances. 800 633-4227).
Place your prescription(s), this form, and your payment in the envelope provided. Be sure the Catamaran Home
CATAMARAN HOME DELIVERY
Delivery address shows through the
PO BOX 696054
window. Do not use staples or paper clips.
San Antonio, TX 78269
Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects. We will alert your pharmacist about possible drug allergies and interactions that can be harmful. To best serve you, we need to know if you have any medication allergies or medical conditions. We also need to know what prescription and nonprescription medications you take regularly.
Your privacy is important to us. Catamaran Home Delivery complies with federal privacy regulations
and will protect this information.

To complete and return this form, follow the steps below.
Step 1: Verify and complete information in SECTION 1.
Step 2: Complete all sections below using blue or black ink. Please print.
Step 3: In the envelope provided, please return the completed questionnaire, along with your prescription
and the mail-order form.
SECTION 1: Patient information
(First name, Last name) (Located on your member ID card and/or in your benefit information.) Month Day SECTION 2: Your medication allergies
Check the box if you have had an allergy or serious reaction to any of these medications.
Aspirin and salicylates (for example: ZORprin®, Trilisate®)Codeine (for example: Tylenol® #3)Erythromycin, Biaxin®, Zithromax®Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil®, Motrin®)Penicillins/cephalosporins (for example: Amoxil®, amoxicillin, ampicillin, Keflex®, cephalexin)Sulfa drugs (for example: Septra®, Bactrim®, TMP/SMX)Tetracycline antibiotics FOR OFFICE USE ONLY
Date of Birth:
SECTION 3: Your medical conditions
Has your doctor ever told you that you have any of the conditions listed below? If so, check the box next to all
Allergies, hay fever (allergic rhinitis) Heart failure (CHF) Hemophilia and hemophilia-like conditions High blood pressure (hypertension) Bladder control problem (urinary incontinence) High blood sugar (diabetes) Brittle bones (osteoporosis) High cholesterol (hypercholesterolemia) Chest pain (angina) Inflammatory bowel disease Migraine headache Overactive thyroid (hyperthyroid) Emphysema (COPD, chronic bronchitis) Peptic, stomach, or duodenal ulcer Enlarged prostate (benign prostatic Poor circulation in the legs (peripheral hyperplasia, BPH) vascular disease) Gastric reflux, heartburn, or esophagitis (GERD) Seizures (epilepsy) Heart attack (myocardial infarction) Underactive thyroid (hypothyroid) FOR OFFICE USE ONLY
SECTION 4: Your nonprescription medications
Fill in the oval completely for each nonprescription medication that you are currently taking on a regular basis.
Orudis KT®/ketoprofen Pepcid AC®/famotidine FOR OFFICE USE ONLY
Additional health information
If you have any other medication allergies, medical conditions, or nonprescription medications not listed above, please call the Member Services phone number on the back of your member ID card. Thank you very much.

Source: http://printjobapplication.com/app/Catamaran-Mail-Order-Form1.pdf