Authorization Of Prescription Transfer Form
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1A
P
T
UTHORIZATION OF
RESCRIPTION
RANSFER
Please complete the following information and our pharmacy staff will work with your current pharmacy or your
prescribing doctor to transfer your existing prescription(s).
P
I
ATIENT
NFORMATION
Last Name: ____________________________________ First Name: _________________________________ Middle Initial __________________
Address: ________________________________________________________________________________________________________________
City: _____________________________________ State: _______ Zip: _______________ Allergies: _____________________________________
M / F
Primary Telephone: (__________) _____________________________
Gender:
Date of Birth_____________________________
P
P
I
REVIOUS
HARMACY
NFORMATION
Pharmacy Name: _________________________________________________________________________________________________________
Pharmacy Telephone: (__________) ___________________________ City: _________________________________________ State: ___________
D
I
OCTOR
NFORMATION
Physician Name: _________________________________________________________________________________________________________
Physician Telephone: (__________) ___________________________
I
I
NSURANCE
NFORMATION
*** Please complete and attach a copy of the patient’s identification and Insurance/Medicare Part D card (both front and back)***
Medicare / Medicaid Number ______________________________ Part D Prescription Plan Name________________________________________
Group #_______________________________ Bin #______________________ Pcn # ______________________ ID # ______________________
(_) Private Health Insurance Company (Workers Comp) _________________________________________________________________________
Member ID # _________________________________________ Phone Number of Insurance Co ________________________________________
R
P
I
ESPONSIBLE
ARTY
NFORMATION
***Please note, the person named as the responsible party must be the same person that signs this form.***
(_) I am my own Responsible Party (RP). OR
Last Name: _________________________________________________ First Name: _________________________________________________
Relationship to Patient __________________________________________ Primary Telephone: (__________) _____________________________
By signing this consent form I hereby authorize Universal Medication Management to begin the transfer prescription process with a UMM
contracted pharmacy. The contracted pharmacy assigned to me is:
Pharmacy Name: _____________________________________________________
Pharmacy Address: ___________________________________________________
Pharmacy Phone: _____________________________________________________
Pharmacy Fax: _______________________________________________________
Any questions regarding your assigned pharmacy, please contact Universal Medication Management toll free at (800) 626-0563.
Responsible Party Signature ________________________________________________ Date _________________
Universal Medication Management
315 S. Beverly Dr. Suite 310, Beverly Hills, CA 90212 / Phone: (800) 626-0563 Fax: 866-268-8262
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