Please submit the form below:

• (Name) As it appears on your insurance card - or full name

• (Email) Your email address should we need to contact you

• (Subject) will be automatically filled in as a transfer request

• (Message Body)

  • Date of Birth

  • Pharmacy currently filling/holding your prescriptions (Name & Location only)

  • List all prescriptions you would like FMS to transfer over

 

Click "submit". Your request will be sent directly to the pharmacy filled shortly!