LDI Pharmacy Services Mail Order Form

Pharmacy Benefit Services - LDI Prescription Refill Order Form

This is a secure order form and is protected by LDI's security certificate. You should see either a lock
in the bottom right hand corner of your computer screen when this form is open the address in your browser should start with 'https:'

Enter up to 10 refills using this form. Fields marked with an asterick (*) are required.

Rx Number*	Drug Name	Qty*	Doctor' Name

*Member Name:

*Member Phone:

*Member ID:

Payment Method:

*Card Number:

Expiration:

Name on Card:

*Delivery Option:

	US Mail
	Pharmacy Pickup
	Courier Service