Prescription Transfer Requests » Student Health Care Center » College of Medicine

Patients currently residing in Gainesville may use the form below to request that their prescription be transferred to the SHCC Pharmacy.

The prescription will be filled once the transfer is complete and if allowed by the insurance.
The patient may contact the SHCC Pharmacy to verify that the prescription is ready for pickup

Prescription Transfer Request Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
UFID #*
Telephone #*
Medication Allergies (list below)*
Are you taking any other medications? (please list all OTC, prescription or supplements):*
Name of Prescription Insurance (Non-Insured applicants enter N/A)*

***NOTE: YOUR PRESCRIPTION INSURANCE IS LIKELY NOT THE SAME AS YOUR MEDICAL INSURANCE**
BIN #*
PCN #*
Group No. #*
Insurance ID #*
Insurance Pharmacy Help Desk Phone Number (back of card)*
Name of Pharmacy where Rx is currently located:*
Telephone # of pharmacy:*
City and State of Pharmacy*
City State / Province / Region
Name of Medication requesting to be transferred:*
Prescription number (if available):
I want to pick up my prescription(s) at (choose one):*
- Student Health Care Center Pharmacy (Infirmary building)
Do you want your prescription to be billed to your insurance?*
- Yes
- No
SHCC @ Shands**
- By checking this box, I request that the SHCC Pharmacy fill the following prescription(s) and have them delivered to SHCC@Shands. I understand the medication cannot be returned for credit or exchange. 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. I understand the co-pay, which the UF Student Health Insurance Plan or other insurance plans do not pay, is my responsibility and will, along with any other charges, 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.
*
- I hereby authorize the SHCC Pharmacy staff to sign for the receipt of my prescription(s) on my behalf to reduce the risk of exposure to COVID-19. If I have any questions or concerns, I will call and speak to a pharmacist at 352-392-1760.
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