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Box 8  \nFremont, Ne. 68026 1-800-228-3108  \n\n| \u003Cbr> SAV-RX MAIL ORDER FORM  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Name:\u003Cbr>| ID\\#: | Group \\#: | |  |\n|  Mailing Address: | City | State | Zip | |\n|  Daytime Phone: | Evening Phone: | |  |  |\n|  Patient Name (if prescription is for other than the cardholder) | Patient Date of Birth: | |  |  |\n\n\n| \u003Cbr> NEW PRESCRIPTION |  |  |  |  |  |  |  |  |  |  |  |  |  | |  | Place Refill Sticker(s) here or complete the information.\u003Cbr>Refill Rx\\#  Drug Name \u003Cbr>Refill Rx\\#  Drug Name \u003Cbr>Refill Rx\\#  Drug Name \u003Cbr>Sav-Rx does not hold prescriptions. Please send only prescriptions to be ordered immediately. Once an order has been processed, it cannot be stopped. We will not accept returns of accurately dispensed medications. |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | 1. Complete the information above\u003Cbr>2. Include your original prescription(s) in an envelope\u003Cbr>3. Include Credit Card information or payment\u003Cbr>* Note: Your physician may escribe your order or phone in your order to 1-800-228-3108 or fax your order to 1-402- 753-2890 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  REFILL |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 1. Complete the information above\u003Cbr>2. Include Credit Card information or payment\u003Cbr>3. To expedite your refill order, you may visit our website [www.savrx.com](www.savrx.com) or download our app from the AppStore or Google Play. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Please charge my Credit Card\u003Cbr>Check One:   |  |  |  |  |  |  |  |  |  | |  |  | Credit Card Expiration Date:\u003Cbr>Month:  Year:  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Credit Card Number: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | CVV: |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Name as it appears on the card:   Cardholder Signature:   Billing Zip Code:  \u003Cbr>Date: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Personal Check or Money Order enclosed. If providing payment by personal check, make payable to Sav-Rx and provide your ID\\# on the check. Mail payment and prescription to Sav-Rx P.O. Box 8 Fremont, Ne. 68026 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| PAYMENT IS REQUIRED FOR ALL ORDERS. IF YOU NEED CURRENT PRICING, PLEASE CALL 1-800-228-3108 TO SPEAK DIRECTLY WITH A CUSTOMER SERVICE REPRESENATIVE. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |","cbCaiaZMx4AFgLCK","https://ap.wps.com/l/cbCaiaZMx4AFgLCK","pdf",515589,"English","# SAV-RX Mail Order Form\n## New Prescription\n## Refill\n## Payment (Credit Card / Check or Money Order)","[{\"question\":\"What information must be completed for a new prescription order?\",\"answer\":\"Complete the customer details and include the original prescription(s) in an envelope. Provide credit card information or payment as instructed on the form.\"},{\"question\":\"How should refill orders be submitted to speed processing?\",\"answer\":\"Complete the form, include credit card information or payment, and place refill details using the Rx# and drug name fields. The form also suggests using the website or downloading the app to expedite refill orders.\"},{\"question\":\"What payment methods are accepted and what payment rule applies?\",\"answer\":\"Payment is required for all orders. Credit card details can be used, or a personal check or money order made payable to Sav-Rx with your ID# on the check.\"}]","SAV-RX Mail Order Form - Order Prescription and Refill | PDF",1789633371]