Prescription Transfer Form

Prescription Transfer Form

Aspirus U.P. Pharmacies
Please fill out and submit the form below to have your prescription(s) transferred to an Aspirus Pharmacy in Michigan’s Upper Peninsula. Please allow at least one business day to complete the transfer and refill any prescriptions needed. For more urgent assistance, please call us at 906-231-8009.
Reason for completing this form:
Select your preferred Aspirus Pharmacy location:
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Phone Number for follow-up (if needed)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Would you like to signup for text message updates to be notified of prescription refills?
If yes: Please provide your preferred cell phone number to receive text messages:
Please enter a valid phone number.Format: (000) 000-0000.
Delivery method of prescription(s)
*Mail order is not available for all medications. If your prescription is eligible for mail order, Aspirus will contact you for payment information. If prescriptions are not eligible, you will be notified prior to filling your medication(s).
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like to provide your insurance details to help us transfer your information into our system?
Upload Image of Your Insurance Card

Cancelof
Insurance Company
Subscriber Number
Prescription BIN Number
Prescription PCN Number
Prescription Group Number
How would you like to provide your prescription(s) details to us?
Upload Prescription(s) to Transfer

Upload an image of each prescription label with the prescription number clearly visible. Upload as many photos as needed in this field.
Cancelof
Prescription(s) to Transfer
Is there anything else we should know about your prescription(s)?
Should be Empty: