Pharmacy Services

Prescription Transfer Form

First Name

Last Name

Date of Birth Format Required: MM/DD/YYYY

Home (Mailing) Address

City

State

ZIP Code

Email Address

Phone Format 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?

Mail

Pick-up

Medication Name

Prescription #

Transferring Pharmacy Name

Transferring Pharmacy Phone #

Prescriber Name

Prescriber Phone #

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

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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.