Want to switch to SHAWANO PHARMACY from your current provider?

To switch your authorization to have your prescription medications and medical supplies provided by Shawano Pharmacy you must first complete and submit a “Consent For Transfer” form below. The first Consent For Transfer Form is for adults, the second form is an Under 18 Form for minors and children in CFS care. Please select the appropriate form – only one needs to be submitted. Miigwetch.

You can also download the appropriate form, complete, sign and fax to 1-833-496-0204.

Consent for Pharmacy Transfer (Adult)

Authorized Consent: I authorize SHAWANO PHARMACY to obtain all prescription profile and information relevant to my pharmacy needs. (Information includes personal health information, contact information, past medical and medication history, insurance/third party payer information, applicable Medication Administration Records/Forms and any other information needed to provide pharmacy services).

I also hereby authorize SHAWANO PHARMACY to become the provider of medications and other pharmacy services. My signature means that:

  • I have read this consent, or have it read to me and understand and agree with its contents
  • I understand the information collected from all sources will be held in strictest confidence

I understand that I may revoke this consent by written statement at any time

Consent for Pharmacy Transfer Form:

Authorized consent for an adult to transfer from their existing pharmacy provider to Shawano Pharmacy

Consent For Pharmacy Transfer (Under 18)

Authorized Consent: As the substitute decision maker, I authorize SHAWANO PHARMACY to obtain all prescription profile and information for the patient identified below, relevant to their pharmacy needs. (Information includes personal health information, contact information, past medical and medication history and insurance/third party payer and any other information needed to provide pharmacy services).
I also hereby authorize SHAWANO PHARMACY to become the provider of medications and other pharmacy services to the patient identified below.

By authorizing the submission of this form I confirm that:

  • I have read this consent, or have it read to me and understand and agree its contents
  • I understand the information collected from all sources will be held in strictest confidence
  • I understand that I may revoke this consent by written statement at any time

Substitute Decision Maker Consent For Transfer Form:

This form is to be completed by an adult Substitute Decision Maker on behalf of a minor including children in CFS care.

Form Downloads (Optional)

Please download the appropriate form below, then print, complete, sign and fax to Shawano Pharmacy at 1-833-496-0204. Miigwetch.