Fillable Printable VA Form 10-0426
Fillable Printable VA Form 10-0426
VA Form 10-0426
Meds by Mail Order Form
Department of Veterans Affairs
A mail order prescription service for qualified CHAMPVA and Spina Bifida beneficiaries
This form is for Prescription Orders Only
Important Information
● This form must be filled out completely including your Social Security number and Date of
Birth for identification purposes. If you cannot be identified, your prescription will not be filled.
● Attach the original prescription to this form. Photocopies of prescriptions are not accepted.
● This order form is required EVERY TIME a written prescription from your medical provider is mailed.
● This form is to be completed by the patient, family member, or caregiver with power of attorney.
● Use a separate form for each patient or family member.
● Medication delivery may take up to 21 days from the date you mail your order. To ensure that you
have enough medication to last until your shipment arrives, request a second written prescription for a
30-day supply from your medical provider that can be filled at your local pharmacy.
● This mail order service is provided only for maintenance medication―that is, medications that are
required for extended periods of time. All immediate-use or one-time-use prescriptions and all CII
controlled substance prescriptions must be obtained at your local pharmacy.
VA FORM
JAN 2016
10-0426
Page 1 of 2
Patient Prescription Information
This form must be filled out completely - TYPE or PRINT information below:
Date of Birth (mm-dd-yyyy)Patient Name: (Last, First, Middle Initial)
Is this a change of address? Yes No
Is this a permanent change? Yes No
Is this a temporary change? Yes No
Patient Mailing Address: Daytime Phone Number (Including Area Code):
NON-SAFETY CAP REQUEST:
Federal law requires that your medication be dispensed in a
container with a child resistant or safety cap. If you would like your
prescription with an “Easy-Open” lid, please sign below:
I request that these prescriptions and all refills of these
prescriptions dispensed in “Easy-Open” or NON-child-resistant
containers.
Signature:
Today's Date:
Home:
Cell:
Address 1
Address 2
City
State
Zip
Medication Allergies
No known allergies
Aspirin NSAIDS
Cephalosporin Penicillin
Codeine Sulfa
Erythromycin Tetracycline
Other (specify)
Arthritis Glaucoma Liver Disease
Asthma Heart Problem Seizures/Epilepsy
COPD High Cholesterol T Thyroid
Depression Hypertension Ulcer/Acid Reflux
Diabetes Kidney Disease
Other (specify) Food Allergy (specify)
Health Conditions
Patient SSN
Mailing Information (Type or Print where the prescriptions are to be mailed)
VA FORM
DEC 2016
10-0426
Page 1 of 2
VA FORM
DEC 2016
10-0426
Page 2 of 2
Telephone: 1-888-385-0235
Address: Meds by Mail
PO Box 20330
Cheyenne, WY 82003-7008
Telephone: 1-866-229-7389
Address: Meds by Mail
PO Box 9000
Dublin, GA 31040-9000
Where to Mail your Prescriptions:
WEST
If you live in one of the following states or
territories, mail your order form to the address
listed below:
Alaska, American Samoa, Arizona, Arkansas,
California, Colorado, Guam, Hawaii, Idaho, Illinois,
Indiana, Iowa, Kansas, Louisiana, Michigan,
Minnesota, Missouri, Montana, Nebraska, Nevada,
New Mexico, North Dakota, Northern Mariana
Islands, Oklahoma, Oregon, South Dakota, Texas,
Utah, Washington, Wisconsin, Wyoming.
EAST
If you live in one of the following districts, states or
territories, mail your order form to the address
listed below:
Alabama, Connecticut, Delaware, Florida,
Georgia, Kentucky, Maine, Maryland,
Massachusetts, Mississippi, New Hampshire,
New Jersey, New York, North Carolina, Ohio,
Pennsylvania, Puerto Rico, Rhode Island, South
Carolina, Tennessee, Vermont, Virginia, Virgin
Islands, Washington D.C., West Virginia.
Provider Name:
Provider Information
This form is for use when you send a paper prescription written by your medical provider. Refill orders
should be placed by calling our automated refill system. Simply call 1-888-370-1699 and follow the voice
prompts. Refill orders may also be placed using the refill slip that accompanies each shipment of
medication. If you choose to reorder by mail, be sure to return your refill slip as soon as you receive your
prescription order, as it may take up to 21 days to process your order. DO NOT DELAY in requesting your
refills. Read the refill slip carefully, it contains information you will need concerning the number of refills
remaining and the prescription expiration date.
How to Request Prescription REFILLS:
We now accept electronic prescriptions directly from your doctor. Ask your doctor if they can e-prescribe
and tell them the name of the pharmacy is listed as: “Meds by Mail CHAMPVA”
E-prescribing Information
Provider Contact:
