Transfer Request

Transfer Prescription Request

Please fill in the form below
Before requesting a transfer:

Please review the following instructions

1. Confirm the prescription you want us to transfer in: Has refills remaining and has not expired.

2. Submit this form.

3. Call Highland Specialty Pharmacy and speak with a staff member to confirm the transfer request. (Nothing will be transferred without verbal confirmation)

Call 601-268-6033 and press option '0' to speak to someone Monday-Friday 9am-5pm CST

4. Please allow 3 business days for Highland to receive the transfer and contact you to set up your order.

If the transfer is time-sensitive, we recommend not submitting the transfer request, and instead, having your doctor send a prescription directly to us.

Please Have your Doctor Send your prescription to:

Fax: 601-268-6690

or

E-Scribe: 2588842

or

Have your Doctor Call: 601-268-6033
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Number:*

Area CodePhone Number
Pharmacy Information
Pharmacy Name*
Name of Pharmacy
Phone Number:*

Area CodePhone Number
Prescription Number(s)
Prescription 1 *
Rx #
Prescription 2
Optional
Prescription 3
Optional
Prescription 4
Optional
Should be Empty: