Forms

Home Delivery Order Form - Medicare

Use this form to ask your doctor to write your prescription for up to a 90-day supply or the maximum days allowed by your plan with refills of up to one year, if appropriate.

Home Delivery Order Form - Medicare

Individual Request for Electronic Protected Health Information

To access your electronic data, please download this form. Complete the form and send it to privacy@express-scripts.com.

Individual Request Electronic PHI

Third Party Request for Electronic Protected Health Information

To make a bulk request for electronic data, please download this form. Complete the form and send it to privacy@express-scripts.com.

Third Party Request Electronic PHI