Text Box: Easy RX Transfer to Hocks Tipp City Pharmacy

Gather the information below and call us, or drop the card off at the Tipp City Store we will take care of the rest. Call us at  667-5803

 

Patient Name_________________________________________  Date of Birth_____________

 

Your Phone Number___________________________________

 

Pharmacy Name ___________________________________________ Pharmacy Phone Number____________________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Drug Name__________________________________________________________________ Rx # if available_________________

 

Get a $5.00 Gas Card for every

Prescription Transferred up to a

Maximum of 5 Cards. Not Valid for

Transfers between Hocks Stores

     Prescription Drug Card Insurance Information 

 

Fill in as much information as you have available.

 

 

Cardholder Name__________________________________________  

 

Relationship to Cardholder _____Self___ Spouse____ Child_____

 

ID Number____________________________________________ Group Number______________________

 

PCN Number _________________   BIN Number_____________________

 

Insurance Company Customer Service Number_________________________________________________

 

Your Address:

 

Street____________________________________________________ Apt #___________

 

City__________________________________________________ Zip_________________

 

 Questions? Call 937-667-5803