Transfer Prescription for UFCW102 Maintenance Medication
Download Transfer Form

The next step is to transfer your medications to Concession Medical Pharmacy.
There are a few ways you can do this:

Online - Fill out the online transfer request form below.

Phone - 1-844-UFCW102 (832-9102)
A pharmacy team member will ask for your current medication information and we will take care of the rest.

Mail - The Transfer form can be downloaded to print and complete, then mail it to the pharmacy in the postage paid envelope provided in your package. Alternatively, if you have written refill prescriptions from your doctor, you can send them to the pharmacy in the postage paid envelope provided in your package.

Fax - 1-844-UFCWfax (832-9329) (Faxes accepted from doctors only)
Have your doctor fax us your refill prescriptions.

Transfer Form

Fields marked with * are required.
Please call your current pharmacy AS SOON AS POSSIBLE to provide consent to transfer your maintenance medication prescriptions.
A pharmacy staff member will contact you with delivery information when your prescription(s) are complete.

  • Patient Details

  • This is used to send you a copy of this transfer form.

  • Pharmacy Information

  • - -
  • Medication Information

  • Any medication directions your physician may have specified on your prescriptions

  • Specify the date that your last prescription was filled.

  • Add Medication

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