We’ll use the information you provide here to contact your pharmacy and transfer your prescription(s) to Indy Scripts Pharmacy. Please use one form per pharmacy.
Current Pharmacy
Pharmacy Phone Number
Drug name#1
Prescription number#1 (optional)
Fill this prescription now?
Yes, fill nowNo, save for later
I would like a 90-day supply, if available
First Name
Last Name
Gender
MaleFemaleOther
Date of Birth (MM/DD/YYYY)
Phone Number
Email Address
We’ll use your email address to send you a confirmation once your request is submitted.
Are you the primary cardholder?
YesNoSkip this step
Relationship to Primary Cardholder
Select OneSpouseChildOther
Primary Cardholder Name
Primary Cardholder Date of Birth (MM/DD/YYYY)
Primary Cardholder Phone Number
If you have insurance, please bring your information to the pharmacy.
Insurance Provider
Provider Phone Number (if available)
Member Number
Group Number (if available)
BIN (if available)
PCN (if available)
Please bring your prescription insurance card to the pharmacy in case we need to verify your information.