Cvs Mail Service Caremarj
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000001921053161007
CVS MAIL SERVICE CAREMARJ
Balance Due Upon Receipt $0.00
033000448
JULIA BRYANT 587 PICKERINGTON HILLS DRIVE PICKERINGTON, OH 43147
Please return the top portion of this form with your payment. See reverse side for payment or refund options.
CAREMARJC
N a m e / R f# JULIA BRYANT Rx# 934983933 JULIA BRYANT Rx# 934984012
Quantity
Retain 'the ~b~6iiom 'portion dffhi'sfdfm 'for'ydur Summary records. for Order: 000001921053161 Date: 04/24/2009 Days Benefit Co-Pay Supply Drug Name / NDC Paid Amount
28 EA
7
12 EA
3
Erythrocin TAB 250MG NDC 00074634620 $0.00 Ibuprofen TAB 800MG NDC 53746046605 $0.00
Provider $3.23* $0.61*
* FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.
Shipping Charge Total for this Order
$0.00
Previous Account Balance Payment Received with this Order by DISCOVER CARD Balance Due Upon Receipt
$0.00 $3.84 $0.00 $3.84 $0.00
A Balance Due may not reflect payments recently mailed separate from this order.
Thank you for your participation. Please remember that you can order refills online at the web address on your id card. If you have any questions, you can contact Customer Care at 1-800-378-8851
Page
1
CVS MAIL SERVICE CAREMARJ
Balance Due Upon Receipt $0.00
033000448
JULIA BRYANT 587 PICKERINGTON HILLS DRIVE PICKERINGTON, OH 43147
Please return the top portion of this form with your payment. See reverse side for payment or refund options.
CAREMARJC
N a m e / R f# JULIA BRYANT Rx# 934983933 JULIA BRYANT Rx# 934984012
Quantity
Retain 'the ~b~6iiom 'portion dffhi'sfdfm 'for'ydur Summary records. for Order: 000001921053161 Date: 04/24/2009 Days Benefit Co-Pay Supply Drug Name / NDC Paid Amount
28 EA
7
12 EA
3
Erythrocin TAB 250MG NDC 00074634620 $0.00 Ibuprofen TAB 800MG NDC 53746046605 $0.00
Provider $3.23* $0.61*
* FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.
Shipping Charge Total for this Order
$0.00
Previous Account Balance Payment Received with this Order by DISCOVER CARD Balance Due Upon Receipt
$0.00 $3.84 $0.00 $3.84 $0.00
A Balance Due may not reflect payments recently mailed separate from this order.
Thank you for your participation. Please remember that you can order refills online at the web address on your id card. If you have any questions, you can contact Customer Care at 1-800-378-8851
Page
1
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