New
Prescription Fax Form
(mail service members)- If your plan includes Walgreens mail service, ask your prescriber to fax us your new or transfer prescription via this form. Please note: We can only accept this form if it is faxed from your prescriber.
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Caregiver Authorization Form
- If you wish to authorize a caregiver or another individual to discuss your medications and health condition with our staff, you must inform Walgreens of your decision by completing this form and mailing it to the Walgreens Privacy Office address as indicated on the form or faxing it to 847-236-0862.
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Member Prescription Claim Reimbursement Form
(Walgreens Health Initiatives members)
- Use this claim form to seek reimbursement for prescriptions obtained without the use of your pharmacy benefit plan. Reimbursement is based on your plan's maximum benefit.
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