SACRED HEART UNIVERSITY – HANCOCK PHARMACY III
MEDICATION DELIVERY ENROLLMENT FORM
Personal Information
Name (Last, First): _____________________________________________________ Date: _________________
Date of Birth: ________________________ Allergies: _______________________________________________
Permanent (Home) Address: ____________________________________________________________________
Mobile Phone Number: __________________________ Email: ________________________________________
Medications will be delivered to:
Sacred Heart University Student Health Services, 4980 Park Avenue, Bridgeport, CT 06604
I would like an automatic refill reminder every month: Yes No
Insurance Information
Insurance Name: __________________________________________ Policy ID: __________________________
RX BIN: ___________________________________ RX Group: ________________________________________
RX PCN: ___________________________________ Medicare ID: _____________________________________
Transferring Pharmacy Information
Pharmacy Name/Address: ______________________________________________________________________
Phone Number: ______________________________________________________________________________
Credit Card Information
Name on Card: _______________________________________________ Card type (Visa/MC/Amex): ________
Card Number: ______________________________________ Exp Date: __________ Security Code: __________
I hereby authorize Hancock Pharmacy III to access my medical records to fill my prescriptions or to transfer my prescription
from my existing pharmacy. I also authorize Hancock Pharmacy III to deliver my prescriptions to Sacred Heart University
Student Health Services on my behalf.
Signature: _____________________________________________ Date: ________________________________
Parent/Guardian Signature (if under age 18): _______________________________________________________
Please submit completed form via fax or email to:
HANCOCK PHARMACY III, 3768 Main Street, Bridgeport, CT 06606
Tel: 203-372-9900 | Fax: 203-372-9902 | hancockpharmacy3@gmail.com
