000001642332276005

C A R E M ACJ A^ R E M A R J C Balance Due Upon Receipt

MAIL SERVICE $0.00
INVOICE/RECEIPT

033000448

JULIA BRYANT
587 PICKERINGTON HILLS DRIVE
PICKERINGTON, OH 43147-1368

Please return the top portion of this form with your payment.
See reverse side for payment or refund options.

CVS Retain the bottom portion of this form for your records.
C A R E M A R JC C A R E M A R JC
Summary for Order: 000001642332276
Date: 12/12/2008
Name / Rx#
Quantity
JULIA BRYANT
Rx# 932702947
90 EA
Days Benefit Co-Pay
Supply______Drug Name / NDC___________Provider Paid______Amount
Sertraline TAB 50MG
90 NDC 00339647511 $19.22 $0. 00*

* FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.

Shipping Charge Total $0.00

for this Order $19.22 $0.00
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD $0.00
Balance Due Upon Receipt $0.00
A Balance Due may not reflect payments recently mailed separate from this order.

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