Prescription Transfer Request

LTC SERVICE TYPE

Select Service Type

LTC at Home

LTC Facilities

PATIENT INFORMATION AND CONSENT

First Name*

Last Name*

Email*

Phone Number*

Date of Birth*

Best time to call

YOUR DRUG INSURANCE INFORMATION

Insurance Name

ID Number

BIN

PCN

Group Number

YOUR CURRENT PHARMACY INFORMATION

Your Pharmacy's Name*

Street Address

City*

State*

Phone Number*

YOUR DOCTOR

Prescriber's Full Name*

Phone Number*

YOUR CURRENT MEDICATION(S)

RX Number

Medication Name*

Strength

Rx	Medication Name	Strength

I would like to receive offers and promotions from TIB Pharmacy.

I authorize TIB pharmacy to contact the transferring pharmacy, prescriber, and myself.