UC Health Prescription Transfer Form

Prescription Transfer Enrollment Form

(required for each family member)
Are you a UC Health Employee?*

YesNo
*Disclaimer: For non-employees, we can fill prescriptions only when ordered by a UC Health provider.
How would you like to receive your prescriptions?*

Pick-upDelivery
Employees - If you selected "Pick-up" in the previous question what is your preferred pharmacy for pick-up?*

UCMC Hoxworth PharmacyWest Chester Outpatient PharmacyUCMC Physician's Office PharmacyUC Health Healing Center PharmacyUCMC Discharge (Outpatient) PharmacyUC Health Specialty Pharmacy
If you selected "Pick-up" in the previous question what is your preferred pharmacy for pick-up?*

UCMC Hoxworth PharmacyWest Chester Outpatient PharmacyUCMC Physician's Office PharmacyUC Health Healing Center Pharmacy
If selecting DELIVERY, please contact the UC Medical Center Hoxworth Pharmacy via phone or email below to provide payment information. Prescriptions for delivery will be processed as received by providers. I authorize the pharmacy staff to bill my credit card/FSA/HSA/debit card on file for my copayments or coinsurance. I understand that any changes to delivery preferences including address changes need to be communicated before shipment occurs.

UC Medical Center Hoxworth Pharmacy

Phone: 513-584-8828

Email: UCMCOutpatientpharmacy@uchealth.com
Patient Name*
Date of Birth MMDDYYYY*

MonthDayYear
Date
Last 4 digits of SSN
Address (cannot deliver to PO box)*
City*
State*
Zip Code*
Preferred Phone*
Secondary phone
Email address
example@example.com
Allergies*
Legal Sex
Gender Identity
Primary Pharmacy Insurance Plan (Name)*
(Name of the Insurance Plan)
Primary Insurance Information (if known, not required)
RX BIN
PCN
ID
Group
Do you have a second pharmacy insurance plan?

YesNo
Secondary Pharmacy Insurance Plan (Name)*
(Name of the Insurance Plan)
Secondary Insurance Information (if known, not required)
RX BIN
PCN
ID
Group
Signature

Clear
Date*

MonthDayYear
Date
Current Pharmacy Information

Please fill as completely as possible to ensure transfer.
Pharmacy Name
Pharmacy Contact Phone Number
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List Your Prescriptions for Transfer

	Prescription #	Prescription Name	Dosage
1.
2.
3.
4.
5
6
7
8
9
10

Should be Empty:

Prescription Transfer Enrollment Form

Current Pharmacy Information