Prescription Transfer Form

Pharmacy Services

First Name

Last Name

Date of BirthFormat Required: MM/DD/YYYY

Home (Mailing) Address

City

State

ZIP Code

Email Address

PhoneFormat Required: xxx-xxx-xxxx

Cell Phone

OK to text?

Yes

Medication Allergies

Preferred Pharmacy

Would you like to pick up your prescriptions at this location or have them mailed to your home?

Pick-up

Mail

Medications

Medication Name

Prescription #

Transferring Pharmacy Name

Transferring Pharmacy Phone #

Prescriber Name

Prescriber Phone #

Insurance

Primary Insurance Carrier

Rx Bin #

Rx PCN #

Rx Group #

ID Number

Secondary Insurance Carrier (if applicable)

Secondary Rx Bin #

Secondary Rx PCN #

Secondary Rx Group #

Secondary ID Number

Comments

I'm not a robot

Please fill out a separate form for all household members/dependents needing prescriptions transferred to a UH pharmacy.

Frequently Asked Questions

What is the turn around time anticipated to transfer prescriptions?: Typically this can be completed within 24 hours depending how long it takes the originating pharmacy to respond to our request.
Will I receive confirmation of the transfer?: Yes, the UH pharmacy will contact the patient once we receive the prescriptions from the originating pharmacy.