Miller Drugdev.millerdrug.com/MillerDrug/media/Miller-Drug/PDFs/mail-order.pdf · l!!!!l!!!!!ift MAIL ORDER FORM: For questions I inquiries, please call: 1\1.\U~r ll Q.!]J.-g Enrollment

l!!!!l!!!!!!ift For questions I inquiries , please call : MAIL ORDER FORM:

1\1.\U~r ll Q.!]J.-g < 800 ) 639 _ 8801 Enrollment & Prescription

Email: [email protected] }} Please fax com~leted form to: (~07) 275 - 3310 Check us out at www. MillerDrug .com Or you may mall to: 401 N Maln St. Brewer' ME 04412

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MARK THIS BOX IF YOUR MAILING ADDRESS IS THE SAMEASYOUR STREET ADDRESS

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FIRST

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CITY I TOWN

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LAST M.l

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STATE ZIP CODE

'''"~--------------------~~~----------------------ADDRESS *THIS INFO CAN BE LEFT BLANK ONLY IF THE BOX

ABOVE IS MARKED CITY I TOWN STATE ZIP CODE

Shipping *Please Mark Your Preferred Option*

• SHIPPING METHOD Estimated# of Days *Cost Please note that processing may take up to 5 business days I I Standard Shipping 5 Business Days $0.00 *The cost associated with faster shipping may change I I

*Faster delivery applies to shipping, NOT processing I I 2nd Business Day 2 Business Days $ 10.00 *Out-of-state shipping will likely cost extra I I

~--J Next Business Day 1 Business Day $ 17.95 Refrigerated shipments will be expedited at no additional cost and can only be sent to a street address, not a P.O. Box.

Geisinger Primary Insurance Cardholder Info

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[All information can be found on member's card]

Cardholder 10 #

Other 3rd Party Insurance Cardholder Info

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Contact Info *PLEASE FILL ALL FIELDS*

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$ 20.95