000001921053161007

CVS MAIL SERVICE

CAREMARJ<I INVOICE/RECEIPT
Balance Due Upon Receipt
$0.00

033000448

JULIA BRYANT
587 PICKERINGTON HILLS DRIVE
PICKERINGTON, OH 43147

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

Retain 'the ~b~6iiom 'portion dffhi'sfdfm 'for'ydur

Summary
records. for Order:
CAREMARJC 000001921053161 Date: 04/24/2009 Days
Benefit Co-Pay Supply Drug Name / NDC Provider
N a m e / R f# Quantity Paid Amount
JULIA BRYANT 28 EA 7 Erythrocin TAB 250MG NDC 00074634620 $3.23*
Rx# 934983933 $0.00
JULIA BRYANT Ibuprofen TAB 800MG NDC 53746046605
Rx# 934984012 12 EA 3 $0.00 $0.61*

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

Shipping Charge Total $0.00

for this Order $0.00 $3.84
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD $3.84
Balance Due Upon Receipt $0.00
A Balance Due may not reflect payments recently mailed separate from this order.

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