Mail Order Refill Request Form: Pharmacy Services, University Health System, Hospital, San Antonio, Texas

Mail Order Request Form

This form may be used to request a prescription from the UHS mail-order pharmacy.

Mail Order Request Form

Processed by DOWNTOWN PHARMACY only. (210) 358-9654 or (210) 358-9657 or Toll Free (800) 760-9654.

Business Hours: Monday thru Friday 8:30 a.m. to 4 p.m.

GENERAL INFORMATION and REQUIREMENTS: • Please allow at least 7 business days for processing and mailing. If you have less than 7 days supply remaining, consider filling a 30 day supply for pick up. • Prior to completing this form, please check the Preferred Drug List on the RX & Go Program website to assure a mailbox is displayed next to your medication. • This form MUST be completed each time prescriptions are requested for mail out. • Prescriptions must be written by a UT Medicine/CMA/UHS Prescriber. • Controlled Substances and medicines that require special handling cannot be mailed. • * Indicates Required Field
Patient Information
*UFCP Patient's Name:
*D.O.B: ex. mm/dd/yyyy
*Daytime Phone #: ex. (210) 999-9999
Home Phone #:
E-mail address (example: john.smith@someisp.com):
Confirmation E-mail address (this needs to match the email address above):
Medical Record #: (8 digits without dashes or spaces - for example: 12345678*)
Insurance Card Member #:
Please Check One: Employee Retiree/Cobra Dependent
Allergies (for person named on prescription): None known Yes (please list):
If a less expensive, generically equivalent drug is available for the brand prescribed, the patient or the patient’s agent may choose between the generically equivalent drug and the brand prescribed: • If no choice is made, the least expensive product will be used. Generic: or Brand:
Mailing Information
*Name:
*Address:
*City, State, and Zip Code:
Check this box if provider has faxed or will fax new prescriptions. (Do not check if this is a refill or transfer request.)

FOR REFILL PRESCRIPTIONS (entire form must be completed each time a refill is requested):
• Check the prescription label to verify you have refills remaining and that the prescription is not expired.
• *If your doctor has changed the instructions for taking a medication, please notify pharmacy and/or submit a new prescription. This will help prevent interruption of therapy if your dose has increased.*
• Please have your doctor give you a new prescription if refills or prescription have expired.
• Refills can be ordered up to 3 weeks early for 90 day supply and 1 week early for 30 day supply."

TO TRANSFER PRESCRIPTIONS from a retail pharmacy
• Prescriber must be UT Medicine, CMA, or UHS.
• Provide the Prescription # or Drug Name & Strength.
• Provide the name and phone number of the retail pharmacy.

Please Complete these four columns of Information for all prescriptions: You MUST provide either the prescription # or Drug Name & Strength, or your request cannot be processed				Also Complete These Two Columns to Transfer Prescriptions from a Retail Pharmacy (Prescriber must be UT Medicine, CMA, or UHS)
Prescription #	Drug Name & Strength	Days Supply/ Qty	Type of Request		Pharmacy Name	Pharmacy Phone #








Number of prescriptions requested: Please check that this number matches the number of prescriptions you entered above. If it does not, please double-check the Prescription # and Drug Name & Strength fields. One of these fields must be filled in for your request to be processed.

My electronic signature below indicates that I have read and reviewed the information submitted and the information is accurate. I also understand that if my address changes for prescritpion mail out or if I choose to pick up my prescriptions at a different location that I indicate here, it is my responsibility to submit my changes to the Rx & Go Program.