HealthPartners.com - Transfer Prescription

Transfer Prescription

Complete all fields of this form for transferring existing prescriptions.
Please Note: Payment is required before shipping. You will need to call Customer Service if your credit or debit card are not on file with us.

PATIENT INFORMATION First Name:

Last Name:

Daytime phone number:

Member Number:

Birth Date:

Allergies:

PHARMACY INFORMATION Provide the information for the Pharmacy you are transferring from Pharmacy name:

Pharmacy phone number:

TRANSFER 1: Drug Name:

Existing Rx Number:

Doctor Name and Phone Number:

Status Your transfer is now on file. Would you like your prescription refilled?
	Yes, fill my prescription and mail now
	No, keep on my prescription on file and I will call to order
TRANSFER 2: Drug Name:

Existing Rx Number:

Doctor Name and Phone Number:

Are you transferring from the same pharmacy as Transfer 1?
	Yes
If no, provide the following: Pharmacy name:

Pharmacy phone number:

Status Your transfer is now on file. Would you like your prescription refilled?
	Yes, fill my prescription and mail now
	No, keep on my prescription on file and I will call to order
ADDITIONAL TRANSFERS If you have additional drugs to transfer list their information here:

Are you transferring from the same pharmacy as Transfer 1?
	Yes
If no, provide the following: Pharmacy name:

Pharmacy phone number:

Status Your transfer is now on file. Would you like your prescription refilled?
	Yes, fill my prescription and mail now
	No, keep on my prescription on file and I will call to order
PAYMENT INFORMATION Have you paid for a mail order pharmacy prescription with a credit or debit card that you would like to use for this transfer?
	Yes
	No
If yes, we should have the credit card number on file. Provide us with: Last four credit card digits:

Four digit expiration date:

If you would like to pay with a different credit/debit card or you do not have one on file call our Customer Service staff at 952-833-0497 or 888-356-6656 with your payment information once you have submitted your transfer. SHIPPING INFORMATION Please allow 3-5 business days from the time we receive your order for processing. Prescriptions will be delivered by the U.S. Postal Service. There is no shipping fee when using the mail order service. Orders cannot be shipped outside the United States. Shipping Address:


(City, State, Zip)