Patient Transfer Form
Please fill this form out so we can transfer your prescriptions to LTC Scripts in the most efficient way possible. Thank you!
Patient Name
First name
Last name
Date of birth
/
Month
/
Day
Year
Date
Gender
*
Female
Male
Phone Number
Please enter a valid phone number.
Drug Allergies (if any)
Facility or Home Address
*
Street Address
Room Number or Apartment Number
City
State / Province
Postal / Zip Code
Email
example@example.com
Social Security Number or Medicare Number (if available)
Current Pharmacy
Current Pharmacy Phone Number (if known)
Type of Packaging Requested
Bingo Cards
Vials
Strip Packaging
Dispill
Effective immediately, I authorize LTC Scripts Pharmacy to transfer all prescriptions from all previous pharmacies for the resident above. LTC Scripts Inc. Participates in many managed care prescription plans. In order to properly submit claims directly to your insurance carrier, we must have a copy of all current insurance cards/information presented/faxed to us before any services can be provided.(medicaid and any secondary insurance this includes medicare, cards). In the event we are unable to directly bill your insurance carrier; payment is required to be made by the patient or the patient’s representation. Copies of receipts of payment will be provided for your reimbursement claim. I agree to use LTC Scripts Inc. For all medication needs & authorize them to bill insurances on behalf of above patient. I further agree that i will be responsible for all pharmacy invoices not reimbursed by insurance for the above patient. Charges for “over the counter”, co pays, deductibles and all other charges will be billed monthly& are the sole responsibility of the guarantor below. All payments are due upon presentation of the invoice for goods and services provided. Finance charges will accrue at 1.5% per month.
Responsible Party
First Name
Last Name
Responsible Party Phone Number
Please enter a valid phone number.
Responsible Party Email
example@example.com
Responsible Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient signature or POA signature
Clear
Date
/
Month
/
Day
Year
Date
Do you want to upload your insurance card right now?
Yes
No
Please either upload a picture of your prescription insurance card or enter the insurance information below. Please also bring in original at time of vaccination.
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