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.

Business Hours: Monday thru Friday 8:00 a.m. to 5:30 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

Please Enter phone on correct format

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)

Allergies(this needs to match the email address above):

None known

Yes (please list):

Please Make sure you enter 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

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:

Also Complete These Two Columns to Transfer Prescriptions from a Retail Pharmacy (Prescriber must be UT Medicine, CMA, or UHS)

You MUST provide either the prescription # or Drug Name & Strength, or your request cannot be processed

xxxxxx

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.

<--- Please Sign Form here