Prescription Benefits, Inc. - Discount Pharmacy Card

Primary Cardholder:

First Name

MI

Last Name

Social Security #





(please print all information)

Mailing Address:

________________________________________

City, State, Zip:

________________________________________
Phone Number: ________________________________________

Email Address:

________________________________________
Type of Membership:
Individual - $48 per year
Family - $60 per year

Method of Payment:

Check Enclosed. Make payable to: Prescription Benefits, Inc.
Charge my:

VISA / MCName (as it appears on card): _____________________________ 
(Circle One)Card Number: ____________________________________
Expiration Date: ___________________


Signature: ____________________________________________________
Print out and mail this application with either the Credit Card information or a check to:

Prescription Benefits, Inc.
P.O. Box 382377
Birmingham, AL 35238-2377

For faster processing:

Go to https://www.rxbenefits.com/discount/ordernow.html
and submit your application securely online,
OR Fax your application to (205) 980-2354.

Fax applications require payment by VISA or MasterCard

form W3-4 ©2003 Prescription Benefits, Inc.