Transfer Request

Transfer Prescription Request

Please fill in the form below
Before requesting a transfer:

Please make sure your prescription is valid and review the following:

Please allow 3 business days for Highland Specialty Pharmacy to receive your 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 Name Last Name
Date of Birth *

Month Day Year
Patient Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Contact Number: *

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

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