HealthPartners.com - Transfer Prescription

Complete this form for transfering existing prescriptions.

PATIENT INFORMATION First Name:

Last Name:

Daytime phone number:

Member Number:

Birth Date:

Allergies:

PHARMACY INFORMATION Provide the information for the Pharmacy you are transferring from Pharmacy name:

Pharmacy phone number:

TRANSFER 1: Drug Name:

Existing Rx Number:

Doctor Name and Phone Number:

TRANSFER 2: Drug Name:

Existing Rx Number:

Doctor Name and Phone Number:

Are you transferring from the same pharmacy as Transfer 1?
	Yes
If no, provide the following: Pharmacy name:

Pharmacy phone number:

ADDITIONAL TRANSFERS If you have additional drugs to transfer list their information here:

Are you transferring from the same pharmacy as Transfer 1?
	Yes
If no, provide the following: Pharmacy name:

Pharmacy phone number:

Select the HealthPartners Pharmacy where you'd like to pick up your transferred prescription:
	Apple Valley Clinic Arden Hills Clinic Bloomington Clinic Brooklyn Center Clinic Como Clinic Coon Rapids Clinic Corporate Pharmacy (HealthPartners employees only) Inver Grove Heights Clinic Maplewood Clinic Midway Clinic Riverside Clinic Specialty Center St. Paul Clinic West Clinic White Bear Lake Clinic Woodbury Clinic
Please note: As required by Minnesota State Law and in order to save you money, this pharmacy will substitute whenever possible an FDA-approved, less expensive, generic drug product, which is therapeutically equivalent to and safely interchangeable with the one prescribed by your doctor, unless you object to this situation. If you prefer a brand-name drug, you may be asked to pay a higher brand-name copay or the cost difference between the brand-name drug and the generic drug in addition to your copay. Do you want a generic equivalent drug?
	Yes
	No