• Prescription Transfer Form

    Please fill out the form below to request a prescription transfer.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Which best describes your gender?*
  • Preferences*
  • Format: (000) 000-0000.
  • Profile Request - Please choose one of the following*
  • How would you like us to proceed once this prescription is transferred to our pharmacy?
  • All done? Please choose one of the following...
  • How would you like us to proceed once this prescription is transferred to our pharmacy?
  • All done? Please choose one of the following...
  • How would you like us to proceed once this prescription is transferred to our pharmacy?
  • All done? Please choose one of the following...
  • How would you like us to proceed once this prescription is transferred to our pharmacy?
  • All done? Please choose one of the following...
  • How would you like us to proceed once this prescription is transferred to our pharmacy?
  • When your prescription(s) is ready, how would you like to be notified?*
  • HIPAA Statement: Your Health Info & Your Privacy

    At Modoc Family Pharmacy, your health information is personal—and we treat it that way. We follow all federal and state laws (like HIPAA) to keep it private and secure.

    How We Use Your Info
    We may use or share your information:

    To treat you or fill your prescriptions
    To bill your insurance
    To improve our services
    To remind you of appointments or offer helpful health options
    We’ll always ask your permission before using your info for things like marketing or sharing certain sensitive records.

    When We Share Without Asking
    By law, we may share your info in special cases, like:

    Emergencies
    Public health reporting
    Legal or court requests
    Help with law enforcement, military, or organ donation
    Serious safety risks

    Your Rights
    You have the right to:
    Ask us not to share your info (we’ll follow if the law allows)
    Get copies of your health records
    Request changes to your records
    Ask us to contact you at a specific address or number
    Know who else we’ve shared your info with
    Be told if there’s ever a breach of your information
    Get a paper copy of this notice
    Questions or Concerns?
    If you have questions or feel your privacy rights were violated, contact us directly.

    We may update this notice from time to time. The current version will always be available at our pharmacy.

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