PRESCRIPTION TRANSFER TO OTIP RAEO MEMBER RX INC.

By completing the below Prescription Transfer form, you authorize the transfer of the specialty drug prescription(s) indicated in the form to OTIP RAEO Member Rx Inc. (“MemberRx”). If you need help completing the form, contact OTIP Benefits Services at 1-866-783-6847.

NOTE: You will need to complete a separate Prescription Transfer form for you and/or each of your family members with a specialty drug prescription(s).

Current Specialty Drug Prescription(s) Information

Specialty Drug Name:* pharmacy name

If the specialty drug name is not listed, you do not need to complete this form.

Second Specialty Drug Name (Optional):

Current Pharmacy Name:

Your current pharmacy name can be found on your most recent prescription label.

Current Pharmacy Phone:

Your current pharmacy phone number can be found on your most recent prescription label.

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First Name of Patient:*

Last Name of Patient:*

Patient Date of Birth:*

Plan Member Information

First Name of Plan Member:*

Last Name of Plan Member:*

Plan Number:*

OTIP ID:*

Contact Information

Email:*

Please use your personal email address to receive timely information and updates. Do not use your school board email address.

Phone:*

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Authorization, Terms and Conditions

Use the scroll tool below to carefully read the authorization, terms and conditions section of this form.

By providing this consent, I understand my personal information, or the personal information of my dependent child(ren) or spouse/partner if applicable, and details concerning any relevant health condition and medication history will be provided by my current pharmacy to MemberRx.
As parent, custodial parent, or legal guardian of my dependent child(ren) of minor or major age, I declare that I have full authority to consent to the collection, use, disclosure, and exchange of any information about him/her/them related to their prescription. I further declare that I am authorized by my spouse/partner to consent to the collection, use, disclosure, and exchange of information pertaining to my spouse/partner regarding their prescription.
I authorize MemberRx to collect, use, retain and disclose my personal information with my health care provider(s), pharmacy, and any other person or organization that may have relevant medical or health information about me, to fulfill my prescription needs and to verify information (“Purposes”). I also authorize MemberRx to contact me to collect clinical and logistics information, to store a patient's record in its Pharmacy Management computer system, and to request a prescription record transfer.
I further authorize OTIP/RAEO Benefits Inc. (“OTIP”), the Third Party Administrator for the group benefits plan, Manufacturer’s Life Insurance Company (“Manulife”), a Canadian insurer that provides group benefits administration and claims payment services for the benefits plan including but not limited to, adjudication and/or payment of prescription drug claims, Cubic Health Inc. (“Cubic”), the entity that runs the FACET Prior Authorization Program, and my current pharmacy to provide any information required by MemberRx to establish my file and dispense my prescription(s) for the Purposes.
By providing your email address, you acknowledge that email security cannot be guaranteed and agree to hold MemberRx harmless of all losses, expenses, or damages that could result by using electronic communications. It is your responsibility to inform MemberRx of a change in your email address or if you wish to withdraw your consent for email communications.

Consent:*

I understand and agree to the terms above.