KentuckyPharmacy-TransferPrescriptionRequestForm

KENTUCKY PHARMACY

TEXT (BEST)/CALL: 502-694-2441 EMAIL: KYPharmacyRx@gmail.com
Prescription Transfer Request Form

Easily Transfer Your Prescriptions to Kentucky Pharmacy
FormType*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Home*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Text-Able is Best)*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Authorized to Text or Email:

TEXTEMAIL
List Drug Allergies
Preferred Language
English, or others
Delivery or Pick-up

DeliveryPick-up
Insurance Company Name:
BIN:
PCN:
GROUP
Insurance Policy Number:
Insurance Phone:
Primary Care Prescriber:
Primary Care Prescriber Phone:
CURRENT PHARMACY NAME:*
CURRENT PHARMACY PHONE:
TRANSFER PRESCRIPTION:*

ALL ACTIVE prescriptions from my current pharmacy to Kentucky PharmacyThe medications listed below from my current pharmacy to Kentucky Pharmacy
LIST THE MEDICATIONS TO TRANSFER TO KENTUCKY PHARMACY
AUTO-REFILL PROGRAM

Please enroll me in the AutoRefill Program. Prescriptions will be filled regularly when due unless/until notified by patient or doctor.
By signing this document, I grant Kentucky Pharmacy permission to transfer selected or all prescriptions from my current pharmacy. I acknowledge my right to choose my pharmacy provider and understand that I can revoke this authorization and switch pharmacies anytime.
Signature*
Signature Date*

MonthDayYear
Date
Should be Empty:

KENTUCKY PHARMACY