Transfer Prescriptions Form

Existing Customers Click Here For Transfer Form
If you have never filled a prescription at John’s Pharmacy, please complete this form. Once we have your profile information and a copy of your prescription(s), transferred prescriptions, or verbal authorization from your doctor’s office, we will fill your prescriptions. If you have any questions about this form or your order, please call us at 1-573-334-1300 or 1-800-540-9222.

Patient Information

First Name :

Last Name :

Middle Initial :

Date of Birth :

Phone Number :

Street Address :

Apartment/Lot Number :

City :

State :

Zip Code :

Social Security Number :

Email Address :

Medical Information

List All Allergies :

Current Medications :
Including all over the-counter medications and pain relievers

Medical Conditions :

Primary Care Physician :

Physician’s Address: :

Physician's Phone No. :

If you have Medicare supplement or replacement insurance, please use fields below to enter insurance information.

Yes

Insurance Information

Do you have Medicare?

Yes

If yes, please complete the following:

ID Number :

Do you have Medicaid?

Yes

If yes, please complete the following:

Issuing State :

ID Number :

Effective Date :

Do you have a spend down?

Yes

Do you have insurance?

Yes

If yes, please complete the following:

Insurance Name :

Subscriber Name :

Subscriber Date of Birth :

ID Number :

Group Number :

Insurance Phone No. :

Usually on back of card

Do you have secondary insurance?

Yes

If yes, please complete the following:

Insurance Name :

Subscriber Name :

Subscriber Date of Birth :

ID Number :

Group Number :

Insurance Phone No. :

Usually on back of card

Prescription Information

Are you transferring prescriptions to John's Pharmacy?

Yes

Transferring from :

Which pharmacy you are transferring from?

Location of Pharmacy :

Specify city and state

Prescription Name/Number :

Other Information

Why did you chose John's Pharmacy?

I acknowledge that I have read John's Pharmacy's Notice of Privacy Practices and understand that I may request a copy of them at any time.

I request that payment of authorized Medicare and insurance benefits be made on my behalf to JOHN'S PHARMACY, INC. for any services furnished to me by that supplier. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents, if needed to determine these benefits or the benefits payable for related services. In addition, I agree to be responsible for payment of supplies billed to Medicare or by other insurance company (listed above), if JOHN’S PHARMACY, INC. Is not reimbursed. I understand that this form will be maintained and made available to Medicare or its representatives. I understand I may request a copy of John’s Pharmacy’s Patient Bill of Rights at any time. I understand that this form will be maintained and made available to Medicare or its representatives.

Please initial :



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Transfer Prescriptions Form Existing Customers Click Here For Transfer Form If you have never filled a prescription at John’s Pharmacy, please complete this form. Once we have your profile information and a copy of your prescription(s), transferred prescriptions, or verbal authorization from your doctor’s office, we will fill your prescriptions. If you have any questions about this form or your order, please call us at 1-573-334-1300 or 1-800-540-9222. Patient Information First Name : Last Name : Middle Initial : Date of Birth : Phone Number : Street Address : Apartment/Lot Number : City : State : Zip Code : Social Security Number : Email Address : Medical Information List All Allergies : Current Medications : Including all over the-counter medications and pain relievers Medical Conditions : Primary Care Physician : Physician’s Address: : Physician's Phone No. : If you have Medicare supplement or replacement insurance, please use fields below to enter insurance information. Yes No Insurance Information Do you have Medicare? Yes No If yes, please complete the following: ID Number : Do you have Medicaid? Yes No If yes, please complete the following: Issuing State : ID Number : Effective Date : Do you have a spend down? Yes No Do you have insurance? Yes No If yes, please complete the following: Insurance Name : Subscriber Name : Subscriber Date of Birth : ID Number : Group Number : Insurance Phone No. : Usually on back of card Do you have secondary insurance? Yes No If yes, please complete the following: Insurance Name : Subscriber Name : Subscriber Date of Birth : ID Number : Group Number : Insurance Phone No. : Usually on back of card Prescription Information Are you transferring prescriptions to John's Pharmacy? Yes No Transferring from : Which pharmacy you are transferring from? Location of Pharmacy : Specify city and state Prescription Name/Number : Prescription Name/Number : Prescription Name/Number : Prescription Name/Number : Prescription Name/Number : Prescription Name/Number : Prescription Name/Number : Other Information Why did you chose John's Pharmacy? I acknowledge that I have read John's Pharmacy's Notice of Privacy Practices and understand that I may request a copy of them at any time. I request that payment of authorized Medicare and insurance benefits be made on my behalf to JOHN'S PHARMACY, INC. for any services furnished to me by that supplier. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents, if needed to determine these benefits or the benefits payable for related services. In addition, I agree to be responsible for payment of supplies billed to Medicare or by other insurance company (listed above), if JOHN’S PHARMACY, INC. Is not reimbursed. I understand that this form will be maintained and made available to Medicare or its representatives. I understand I may request a copy of John’s Pharmacy’s Patient Bill of Rights at any time. I understand that this form will be maintained and made available to Medicare or its representatives. Please initial :


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