Supplemental Forms

You may download and print the following forms:

Enrollment Activation Form

Medco Health Home Delivery - Pharmacy Services™ Order Form

Health, Allergy, and Medication Questionaire

Nomination Form

Please take a minute to make sure…

• You have included your doctor’s signed Prescription form and filled out the patient Information on the front of the order form for each new prescription.
• You have either filled out the credit card Section on the front of this order form or Included a check or money order for the Required co-payment.
• You have written your member ID on any check or money order.
• The Medco Health address is correct on your mailed envelope.
• You have filled out the Health, Allergy, and Medication questionnaire. This information Will help Medco Health better serve your Prescription drug needs.

Expedited shipping available for an additional fee, your order will be shipped by an expedited service offered to your area. This option must be chosen when you make the order and cannot be applied after an order is already processed.