SHCC@Shands Prescription Delivery

Permission to Deliver Prescriptions to SHCC@Shands

I 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 Information

Student Health Care Center Prescription (Rx) number or name of medication for refill - separate multiples with commas:*

Do you need oral contraceptives (birth control pills)?*

No

Other - Please specify how many total packs you need.

Do you have any drug allergies?*

No

Other - Please describe drug allergies in detail.

I will pick up my order AFTER 2PM on the date specified:*

Patient Name*

First Last

UF ID Number*

Primary Phone*

Insurance Company Information

Insurance Company Name*

SHCC Pharmacy has my insurance information on file. OR

Other - Insert name of insurance company AND complete the insurance policy information fields below.

Insurance Bin Number

Insurance Group Number

Insurance ID Number

Third Party Pick Up of Medications

Please 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@Shands

Are you sure you want your prescription delivered to SHCC@Shands, located in the Dental Tower of the Health Science Center on Archer Road?*

Yes
No

If you need a prescription filled at the SHCC Pharmacy in the Infirmary Building, please call (352) 392-1760.

University of Florida

Student Health Care Center