Rx Transfer - Rose Pharmacy

Transfer Your Prescriptions to Us:

Please take a few minutes to complete this prescription transfer form. Information provided will be kept confidential and will help your pharmacist in reviewing your medication. We take numerous insurances, such as, Optum RX, Anthem, Aetna, BlueCross, Humana, United, HealthFirst, Cigna, Oxford, CVS Caremark, All Medicare Part D, and many more.

"*" indicates required fields

Full Name*

Date of Birth:*

Full Address:*

Current Pharmacy Address:*

*Preferred Phone:*

Home

Work

Cell

Phone Number:*

Email:*

*Gender:*

Male

Female

Undisclosed

*Allergies:*

No Known Allergies

Allergies: (Please use comma to list.)

*Details About Allergies:*

*Container:

I request my prescriptions be placed in a non-child resistant container.

CONSENT TO ALLOW ROSE PHARMACY TO USE AND DISCLOSE INFORMATION

CONSENT: By entering your initials below, you consent to the use and disclosure of your protected health information by Rose Pharmacy, our staff, and our business associates for treatment, payment, and health care operations.

NOTICE OF PRIVACY PRACTICES: You certify that "I have read Rose Pharmacy's Notice of Privacy Practices." You have the right to request the we restrict our uses or disclosures of your protected health information, which we are otherwise permitted to make, for treatment, payment, and health care operations, although we are not required to agree to these restrictions. However, if we agree to further restrictions, they will be binding on us.

RIGHT TO REVOKE CONSENT: You have the right to revoke the consent in writing, except to the extent that we have taken action in reliance on it.

*Print Name:*

*INITIALS:*

*Date:*