Locate and fill-out the form you need from the list below.
Doctor's New Rx Form For use by your doctor to submit a new prescription to the WellDyne mail pharmacy.
Mail Service Order Form This form should accompany your prescription orders. You can print and mail this form in along with your new prescription. If you choose to fax in the form, your physician must phone or fax in your prescription(s).
Protected Health Information Authorization Authorization for WellDyne to provide access to Members Protected Health Information (PHI) to another Individual