Form 10-10068 VA meds by mail order form

Department of Veterans Affairs

Meds by Mail Order Form

A mail order prescription service for qualified Camp Lejeune Family Member Program
This form is for Prescription Orders Only
Important Information
● This form must be filled out completely including your Social Security number and Date of Birth for
identification purposes. If you cannot be identified, your prescription will not be filled.
● This form is to be completed by the patient, family member, or caregiver with power of attorney.
● Use a separate form for each patient or family member.
● This order form is required EVERY TIME a written prescription from your medical provider is mailed.
● Attach the original prescription to this form. Photocopies of prescriptions are not accepted.
● Your medication delivery may take up to 21 days from the date you mail your order. To ensure that
you have enough medication to last until your shipment arrives, you may need to request a second
written prescription from your medical provider that can be filled at your local pharmacy.
● This mail order service is provided only for maintenance medication―that is, medications that are
required for extended periods of time. All short-term or one-time-use prescriptions must be obtained
at your local pharmacy. Meds by Mail primarily dispenses generic medications; if you need a brand
name product when a generic is available you will have to use your retail pharmacy.
How to Request Prescription REFILLS:
This form is for use when you send a paper prescription written by your medical provider. Refill orders
should be placed by calling our automated refill system. Simply call 1-888-370-1699 and follow the voice
prompts. Refill orders may also be placed using the refill slip that accompanies each shipment of
medication. If you choose to reorder by mail, be sure to return your refill slip as soon as you receive your
prescription order, as it may take up to 21 days to process your order. DO NOT DELAY in requesting your
refills. Read the refill slip carefully, it contains information you will need concerning the number of refills
remaining and the prescription expiration date.
Privacy Act Information and Paperwork Reduction Act Notice
The information requested on this form is solicited under the authority of 38 C.F.R. §17.32. It is being collected to
document your preferences for your health care in the event that you can't speak for yourself anymore. The
information you provide may be disclosed outside the VA as permitted by law. Possible disclosures include those
that are described in the "routine uses" identified in the VA system of records 24VA19, Patient Medical Record-VA,
published in the Federal Register in accordance with the Privacy Act of 1974. This is also available in the
Compilation of Privacy Act Issuances at http://www.gpoaccess.gov/privacyact/index.html. You may choose to fill out
this form or not. But without this information, VA health care providers may not understand your preferences as well.
If you don't fill out this form, there won't be any effect on the benefits you are entitled to receive. The Paperwork
Reduction Act of 1995 requires us to let you know that this information collection follows the clearance requirements
of section 3507 of this Act. We estimate that it will take you about 5 minutes to fill out this form, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the information you write down. A Federal agency may not conduct or sponsor, and a person is not
required to respond to a collection of information, unless it displays a current valid OMB control number. The OMB
Control No. for this information collection is 2900-XXXX.
OMB: 2900-XXXX

Burden:5 minutes

Expiration: XX/XX/XXXX

Page 1 of 3

Where to Mail your Prescriptions:

WEST

EAST

Alaska, American Samoa, Arizona, Arkansas,
California, Colorado, Hawaii, Idaho, Illinois,
Indiana, Iowa, Kansas, Louisiana, Michigan,
Minnesota, Missouri, Montana, Nebraska, Nevada,
New Mexico, North Dakota, N. Mariana Island
Oklahoma, Oregon, South Dakota, Texas, Utah,
Washington, Wisconsin, Wyoming.

Alabama, Connecticut, Delaware, Florida,
Georgia, Guam, Kentucky, Maine, Maryland,
Massachusetts, Mississippi, New Hampshire,
New Jersey, New York, North Carolina, Ohio,
Pennsylvania, Puerto Rico, Rhode Island, South
Carolina, Tennessee, Vermont, Virginia, Virgin
Islands, Washington D.C., West Virginia.

Telephone: 1-888-385-0235

Telephone: 1-866-229-7389

Address:

Address:

If you live in one of the following states or
territories, mail your order form to the address
listed below:

Meds by Mail
PO Box 20330
Cheyenne, WY 82003-7008

OMB: 2900-XXXX

If you live in one of the following districts, states or
territories, mail your order form to the address
listed below:

Burden:5 minutes

Meds by Mail
PO Box 9000
Dublin, GA 31040-9000

Expiration: XX/XX/XXXX

Camp Lejeune Family Member Program
Patient Prescription Information. This form must be filled out completely.

Patient Name: (Last, First, Middle Initial)

Patient SSN

Date of Birth (mm-dd-yyyy)

MAILING INFORMATION
Daytime Phone Number (Including Area Code):

Patient Mailing Address:

Home:
Cell:

Is this a change of address?

Yes

No

Is this a permanent change?

Yes

No

Is this a temporary change?

Yes

No

(A temporary address will not affect your permanent address,
only where your meds are being mailed. A temporary address
will not change until you notify Meds by Mail.)

Medication Allergies
None

Morphine

Aspirin

NSAID (ex. Ibuprofen)

Cephalosporins

Penicillin (ex. Ampicillin)

Codeine

Sulfa (ex. Bactrim, Septra)

Erythromycin

Tetracycline (ex. Minocycline)

Other (specify below)

Food Allergy (specify below)

Medication Name

NON-SAFETY CAP REQUEST:
Federal law requires that your medication be dispensed in a
container with a child resistant or safety cap. If you would like your
prescription with an "Easy-Open" lid, please sign below:

Signature:

Date:

Health Conditions
Bladder cancer
Breast cancer
Esophageal cancer
Kidney cancer
Lung cancer
Scleroderma
Leukemia
Multiple myeloma
Other (specify below)

Myelodysplastic syndrome
Non-Hodgkin's lymphoma
Hepatic steatosis
Renal toxicity
Neurobehavioral effects
Female infertility
Miscarriage

Name of Medical Provider Who Signed the Prescription

1
2
3
4
5
6
7
8
OMB: 2900-XXXX

Burden:5 minutes

Expiration: XX/XX/XXXX

Page 3 of 3