SHCC@Shands Prescription Delivery Permission to Deliver Prescriptions to SHCC@ShandsI request that the SHCC Pharmacy fill the following prescription(s) and have them delivered to SHCC@Shands. The medication cannot be returned for credit or exchange.PLEASE NOTE: If not picked up within 48 hours of the date stated here, the medication will be restocked and I will be charged a $3 restocking fee. I authorize the Nurse in Charge to act as my agent in receipt of the medication, if delivered. I authorize release of information required to process insurance claims and/or bill this payment. The co-pay, which the UF Student Health Insurance Plan does not pay, and any other charges will be placed on my myUFL account. I understand that if I have medication-related questions I can call 1-866-941-1760 during regular business hours to speak to a pharmacist.PLEASE NOTE: NEW prescriptions OR prescriptions that you wish to TRANSFER to the SHCC Pharmacy MUST BE CALLED IN (352-392-1760) OR FAXED (352-846-1521). We CANNOT fill them with this form.Prescription & Patient InformationStudent Health Care Center Prescription (Rx) number or name of medication for refill - separate multiples with commas:*Do you need oral contraceptives (birth control pills)?*NoOther - Please specify how many total packs you need.Do you have any drug allergies?*NoOther - Please describe drug allergies in detail.I will pick up my order AFTER 2PM on the date specified:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Name* First Last UF ID Number*Primary Phone*Insurance Company InformationInsurance Company Name*SHCC Pharmacy has my insurance information on file. OROther - Insert name of insurance company AND complete the insurance policy information fields below.Insurance Bin NumberInsurance Group NumberInsurance ID NumberThird Party Pick Up of MedicationsPlease fill out below if you need a someone else to pick up your medication(s).Third Party Name First Last I authorize the person(s) named here to pick up my medication(s) and sign for the charges or release medical information for billing.Confirmation of delivery to SHCC@ShandsAre you sure you want your prescription delivered to SHCC@Shands, located in the Dental Tower of the Health Science Center on Archer Road?*YesNoIf you need a prescription filled at the SHCC Pharmacy in the Infirmary Building, please call (352) 392-1760.