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(click here►) Medicare D Ordering*
FREE USPO Ground shipping on orders whose cost is over $150.00*(see terms and conditions for full shipping details)

 Special FREE service team for processing Medicare D Cancer & HIV medication reimbursement problems!
   Toll Free 800-764-3648     Phone (516) 467-2500      Fax Toll Free 866-843-4154  Fax 866-845-3750  Fax 516-467-2539


Refill Order Form
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Patient Information:
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Last Name:
Daytime Phone Number: () -
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RxUSA account #:
Payment:
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Call me for bank card number
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We can not ship unless you accept a form of order confirmation.
e-mail notification is acceptable to release my order
notification to my phone or voice mail is acceptable to release my order
no notification is needed by me, release my order
 

Refill Drugs Requested

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Prescription #: Drug Name/Description:  Quantity:

Do you need a paper order form included with your order? No Yes

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(Valid phone number or email address required for order confirmation.)

IP 38.103.63.18 located 38.103.63.18 .

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We do not fill prescriptions for Controlled Substances!!!. All prices quoted, and orders shipped, are billed and shipped FOB New York City . No returns may be accepted for drugs and medication, in accordance with Federal and State regulations governing prescription drugs and medications. All Prescriptions received by Phone, Fax, E-Mail, or Mail, from Patients, Physicians, Clinics, Hospitals, or other health care professionals, are received by our Pharmacy, in New York State, and are subject to being filled under the jurisdiction and laws and regulations of the State of New York and of appropriate Federal regulations if applicable. Delivery of your medication, regardless of the address you designate will be construed to have been made in the State of New York by our giving your order to Airborne Express, DHL or FedEx for delivery to you. Your transmission to us, of your prescription, and request to have the medication shipped to you at any designated address is an acknowledgement that you have read this notice and agree that New York State and Federal laws and regulation, govern and control, as to this prescription order, and will be subject only to New York State law and jurisdiction.

 
Toll USA Free Phone (800) 764-3648
Alternate Phone (516) 467-2500  
FAX (516) 467-2539  FAX TOLL FREE USA (866) 843-4154
FAX (516) 467-2541  FAX TOLL FREE USA (866) 845-3750		 RxUSA Administrative Office
RxUSA Inc. DUNS# 107979960
81 Seaview Blvd.
Port Washington, NY 11050
RxUSA Pharmacy HMO/PBM
RxUSApbm Inc.  NYS REG#25934
81 Seaview Blvd. NPI # 1265537294   NABP#3333248
Port Washington, NY 11050
 
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