Healthcare Pharmacy Relocation Form

HEALTHCARE PHARMACY RELOCATION FORM

This Pharmacy Relocation Form documents patient authorization and instructions regarding the transfer of prescription medications, prescription records, and related protected health information (PHI) to a new pharmacy location as a result of pharmacy relocation, change of provider, or at the request of the patient. Complete all applicable sections. Sign and date where indicated to authorize release and transfer of records and prescriptions.

Patient Information

Date of birth:    Gender:

Current Pharmacy Information

New Pharmacy Location Details

Effective relocation date:    Temporary closure during relocation:

Prescription Records & Transfer Instructions

I authorize the current pharmacy to transfer the prescription records listed below to the new pharmacy noted above. If left blank, authorization applies to all non-controlled prescriptions maintained at the current pharmacy unless otherwise restricted by law.

Insurance & Billing

Authorization to Release Protected Health Information (PHI)

By signing below, I authorize the current pharmacy named above to disclose and transfer my prescription records, medication history, insurance billing information, and any related PHI necessary to effectuate the transfer of my prescriptions to the new pharmacy named above. This authorization includes communication with prescribing practitioners, pharmacies, and third-party payers as necessary to obtain refill authorization and to coordinate continuity of care.

I understand and acknowledge that: (a) controlled substances may be subject to federal and state restrictions on transfer and may not be transferrable under applicable law; (b) the new pharmacy may require verification from my prescriber before filling or refilling prescriptions; (c) my insurance coverage and copay responsibility may change based on the new pharmacy or relocation; and (d) this authorization does not require any provider to prescribe a controlled substance or provide services prohibited by law.

Check applicable release scope:
I authorize transfer of all prescriptions and medication records held by the current pharmacy.
I authorize transfer only for the medications listed in the Prescription Records & Transfer Instructions section and any additional medications specifically listed below.

Authorization expiration date (if any):

Communications & Notifications

I consent to the following communications regarding this relocation and my prescriptions (select all that apply):
Phone calls to primary phone
SMS/text messages to primary phone
Email notifications
I authorize leaving messages that may include basic prescription information:

Privacy Notice Acknowledgment

I acknowledge that I have been offered or provided with the pharmacy's Notice of Privacy Practices explaining how my PHI may be used and disclosed. I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Medical History / Current Medications (summary)

Certifications and Signature

By signing below I certify under penalty of perjury that I am the patient named above or the patient's legally authorized representative. I authorize release and transfer of prescription records as indicated and confirm that information provided on this form is true and correct to the best of my knowledge. I understand that falsifying information may subject me to legal penalties and may affect the continuity of my medication therapy.

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