RX TRANSFER

RX Transfer Form
Patient's Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender? *

Male Female Other
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Pharmacy's Information
Old Pharmacy's Name *
Old Pharmacy's Phone Number *
Please enter a valid phone number.
Old Pharmacy's Fax Number
Please enter a valid phone number.
Prescriptions being Transferred (Give Rx numbers if available) *
RX Insurance and Medical Insurance examples
For the RX Insurance card, they generally have the following information: RX BIN#, RX PCN#, RX GROUP#, RX MEMBER ID#.

You can see some examples at:
https://escopharmacy.nyc/pages/medical-insurance-example

For Medical Insurance, you can find example at the link here:
https://escopharmacy.nyc/pages/medical-insurance-examples.
Please upload your pharmacy insurance card here (Front and Back) *

Cancel of
Doctor's Information
Doctor's name:
Doctor's Phone Number:
Please enter a valid phone number.
Doctor's Fax Number:
Please enter a valid phone number.
Please sign with your full name: *

Clear
Should be Empty: