Fill and Sign the New Jersey Commercial Rental Lease Application Questionnaire Form

PLEASE PRINT and COMPLETE SECTIONS 1-5 Section 1 Complete this section for you and your eligible dependents the first time the person orders medication, and when any changes occur. In the Comments area at right, list all medications being taken by each family member ordering medication so we can review for potential interactions. Provide additional information on a separate sheet if necessary. If anyone goes by a nickname, please write the name in the appropriate space below. Member Name Last Sex: M First M.I. No known allergies F Sulf (Ganotrnamide D isin, G erivati antan ves ol, etc Tetrac .) ycline s Eryth romyc in Local anesth etics Morph ine an d Deri vative s Penic illin Propo (Darv xyphen on, D e arvoc et, etc Sulfa .) Please mark an “X” in the appropriate box for any allergies you or others listed on the form may have. Comments Aspir in Cepha (Kefle losporin x, Duri Antib cef, e iotics tc.) C ode ine Insurance company Ampic illin If anyone has other insurance coverage, please enter name of insurance company and check box below. Ace min (Tyleta nol) ophen Alcoh ol Allergies: Nickname Other Ins. Coverage Physician: Spouse Member ID # (from health plan ID card) Name Last Sex: M First Birth Date M.I. No known allergies F Dependent Last M First Birth Date M.I. No known allergies F Dependent Last M First Birth Date M.I. No known allergies F Drink Alcohol Smoker Pregnant Contact Lenses Drink Alcohol Smoker Pregnant Contact Lenses Drink Alcohol Smoker Pregnant Contact Lenses Drink Alcohol Nickname Physician: Name Contact Lenses Other Ins. Coverage Member ID # (from health plan ID card) Sex: Pregnant Nickname Physician: Name Smoker Other Ins. Coverage Member ID # (from health plan ID card) Sex: List below any other allergies and all medications, including over–thecounter medications, each person is currently taking. Also list any illnesses or medical conditions (i.e., asthma, blood pressure). Use a separate sheet if necessary. Nickname Other Ins. Coverage Physician: Member ID # (from health plan ID card) Birth Date TNA Section 2 To order: Enclose your original written prescription(s). IMPORTANT: TO AVOID DELAY - PLEASE ENCLOSE CHECK, MONEY ORDER OR CREDIT CARD NUMBER FOR PROCESSING. Section 3 Complete this section indicating how you wish to pay for your medication. Please do not send cash AMOUNT ENCLOSED $ Check or money order enclosed Charge to my credit card Cardholder Charge this and all future Name orders to this credit card Cardholder Signature CHECK NO. Account Number Expiration Date Section 4 Master Card Tell us where to ship your order Discover Card VISA Home Phone ( ) Daytime Phone ( ) Date Check here for address change Member I.D. Number Name Last First M.I. Mailing Address City Street Doctor’s Phone ( ) American Express P.O. Box Doctor’s Name State Apt. No. Zip Code Group/ Employer Name Dr. Section 5 Special Handling Required: I certify that all information on this form is correct. I permit Express Scripts to release all information to plan sponsor, administrator or underwriter. X Non-Child-Resistant Containers Please sign below if you want prescriptions for you or your eligible dependents dispensed in non–child–resistant containers. X Signature Required I request this and all future orders be shipped “signature required”. I understand there will be an extra charge for this service. Signature Required If you wish to resume receiving child-resistant containers, please check box. PLEASE INCLUDE THE FOLLOWING ITEMS IN YOUR ENVELOPE Your new prescription(s) Your refill slip(s) Your coinsurance/copayment (if required) for each prescription Your credit card number and expiration date if paying by credit card. Your check or money order payable to: Express Scripts Insert completed Sections 1-5 A convenient method to obtain prescription drugs covered under your pharmacy benefit plan. Prescription Drugs Delivered by Mail to You by Express Scripts Questions & Answers This brochure only describes your mail-order prescription drug service. Please refer to your benefit plan documents for information regarding your prescription drug benefits. Prescriptions submitted for medications that are not covered will be returned to you unfilled. Refer to your benefit plan documents for information on covered prescriptions. While this information is believed to be accurate as of the print date, it is subject to change without notice. How Do I Order My Medications? Just follow these simple steps to order your covered maintenance prescriptions: 1. Ask your doctor for two signed prescriptions... ...one for an initial supply to be filled at your local participating pharmacy (if your benefits plan provides for local pharmacy and mail-order) ...the second for up to a 90 day supply with refills, if authorized, that you mail to Express Scripts once you and your doctor determine that the medication is right for you. 2. Print your name, address and health plan member ID number on the back of each prescription. 3. Complete the attached Order Form and Patient Information for you and your eligible dependents who will be obtaining medications through the mail. You will not need to complete this entire form when ordering refills, unless your patient information or your order has changed. 4. Mail your Order Form and Patient Information, your original written prescription(s) and your copayment(s) to Express Scripts, Inc. at the complete address below. (Refer to your plan of benefits for the applicable copayment amount or call the toll-free Member Services phone number on your member ID card.) When Will I Get My Prescription? Generally, your medication will be delivered to you, postage paid, by U.S. mail or other carrier within 14 days. If you submit insufficient information to process your prescription order, or if we need to contact you or your prescribing physician, delivery could take longer. Prescriptions can be shipped via overnight carrier for an additional charge. Will I Get Generic or Brand-Name Drugs? That depends on you and your doctor. You may save money with FDA-approved generic equivalents. Where permitted by applicable law, generics may be dispensed when appropriate and permitted by your physician. Please refer to your benefit plan documents for information regarding any applicable limitations and conditions. How Do I Order Refills? • Print your name and health plan member ID number on the order form supplied by Express Scripts and complete Section 3. Remember to enclose a check (if applicable). Place these items in an envelope at least three weeks prior to the time your current supply runs out and mail to Express Scripts. Orders placed less than 30 days before the expected refill date will be held until a refill is allowed. Most prescriptions, including refills, expire within one year (sometimes sooner) from the date they are written. After the expiration date, you must get a new prescription from your doctor, even if your prescription label still shows that there are refills remaining. Can I Combine My Prescription and Refills to Get More Medication at One Time? No, you can only obtain amounts authorized by your physician. For example, if your physician writes your prescription for a 30-day supply with two refills, you can only receive a 30-day supply at a time. PLEASE ALLOW 2 WEEKS FOR DELIVERY If you have a question about your pharmacy benefit, call the number on your ID card. Hearing Impaired: 1-800-305-5376 For Refills Call 24 Hour, Touch Tone Service 1-877-849-5521 MLR602APDF (09/01) MAIL TO: MAIL PHARMACY SERVICE ATTN: TNA PO BOX 27965 ALBUQUERQUE, NM 87125-7965