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Transfer Form

Serve You Rx Home Delivery Pharmacy Transfer Form

One form per patient
All fields are required unless marked as optional

If you currently use a mail service or local pharmacy to fill your prescriptions, you can easily transfer them to Serve You Rx Home Delivery Pharmacy by completing this form. An order will be placed for all prescriptions marked “Fill”. If you need additional forms, click here.

PRESCRIPTION BENEFIT CARDHOLDER INFORMATION

Look for the following information on your prescription ID card.

Prescription Benefit Plan Name:

Member ID #: Rx Group #: Rx BIN #: PCN:

Last Name: First Name: MI: (opt.)

Date of Birth:

Gender: Male Female Other

Email Address:

Permanent Address: City: State: ZIP:

Use a different address for deliveries

Delivery Address: City: State: ZIP:

Primary Phone #:

Mobile Work Home

Alternate Phone #:

Mobile Work Home

MEDICATION ALLERGIES

No known allergies

Amoxil/Ampicillin

Aspirin

Cephalosporins

Codeine

Erythromycin

Iodine

Penicillin

Quinolones

Sulfa drugs

Tetracyclines

Others:

HEALTH CONDITIONS

None

Acid Reflux

Arthritis

Asthma

Depression

Diabetes

Epilepsy

Glaucoma

Heart problem

High blood pressure

High cholesterol

Migraine

Osteoporosis

Prostate issues

Thyroid – low/high

Others:

Over-the-counter/herbal medications taken regularly: None

PAYMENT & SHIPPING

A pharmacy representative will contact you prior to shipment of your first order to set up a payment method.

Standard processing time for orders is 2–3 business days from the date the completed order is received at the pharmacy. Please allow additional time for delivery when placing your order. Serve You Rx will contact you if there will be a delay in processing your order. Once shipped, medications may not be returned for a refund or adjustment.

Prescription Transfer Information

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Rx #: Drug Name/Strength:

Fill

Do Not Fill at this time

Fill and Place on EZAutoFill (automatic refill) EZAutoFill is not available to Medicare Patients

Prescriber Name: Prescriber Phone #: (opt.)

Pharmacy Name: Pharmacy Phone #:

Additional information for pharmacy team: (opt.)

Thank You!

Thank you for your submission. Your transfer form has been received and a pharmacist will attempt to transfer your prescriptions within 2-3 business days. Please note if there are no refills remaining on your prescription we will contact your physician for authorization.

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About Serve You Rx

We have been an independent, privately held, full-service PBM since 1987. Built on a reputation for service excellence, we have expanded our capabilities from the ground up with our hardworking team and proven process for managing drug spend with innovative and cost-effective benefit solutions.

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About Serve You Rx

We have been an independent, privately held, full-service PBM since 1987. Built on a reputation for service excellence, we have expanded our capabilities from the ground up with our hardworking team and proven process for managing drug spend with innovative and cost-effective benefit solutions.

Company

Home

About Us

careers

Contact Us

Partners

Partners Home

What We Do

Who We Are

Pharmacies

RFP Form

Providers

Providers Home

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Provider's Forms

Members

Members Home

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EZRefillRX

FAQs

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