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Cvs Mail Service Invoice/Receipt
Cvs Mail Service Invoice/Receipt
Cvs Mail Service Invoice/Receipt
033000448
JULIA BRYANT
587 PICKERINGTON HILLS DRIVE
PICKERTNGTON, OH 43147
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 Summary for Order: 000001911503482
Date: 02/19/2009
Name / Rx# Days Benefit Co-Pay
Quantity Supply______Drug Name / NDC___________Provider Paid______Amount
JULIA BRYANT
Rx# 933931042 Synthroid. TAB 0.IMG
90 EA 90 NDC 00339635111 $0.00 $12.52*
* FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.
Thank you for your participation. Please remember that you can order refills online at the web address on your id card.
If you have any questions, you can contact Customer Care at 1-800-378-8851 Page 1