Step 3: Keystone Professional Pharmacy - NJY Medication Form

NJY Camps partners with Keystone Pharmacy

The medications you enter below will only apply to the child you specify below. You will need to fill out this form for each child taking medicine.

Please read the following instructions and then fill out your child's prescriptions and OTCs in the form below.

  • PLEASE NOTE that Keystone is unable to fill some C2 prescriptions (Controlled Substances) due to the national drug shortage. Please contact Keystone directly to determine if the C2 your student is on is one that the pharmacy can get through their vendor. KPP does not fill Inhalers, EpiPens, Injectables, Growth Hormones, Birth Control Prescriptions, or Acne Meds topicals and gels.

  • Parent’s instructions on the medication form must match the prescriptions.
    The most common discrepancies are:
    TIME OF THE DAY (Example: Breakfast, Lunch, Afternoon, Dinner, or Bedtime)

  • Please upload your prescriptions below if handwritten or hand signed.

  • If there are discrepancies Keystone Pharmacy will send an email to the parent to clarify.

  • Once the medication form is submitted, medication CHANGES can be communicated to KPP via a CHANGE MEDICATION FORM available here.

  • We have a discounted Formulary list of Meds. The cost for OTC Medications chosen from this pre-selected list (called the Formulary) have a discounted flat rate of $8.00 per 30 day supply versus a minimum of $12.00 per 30 day supply for OTC meds not listed on the Formulary. There are significant cost savings for choosing OTC Meds from the Formulary since any OTC Meds not chosen from the Formulary are billed at market cost with a minimum of $12. View Formulary

Individual Child Medication and OTC Form

Child Name(Required)
MM slash DD slash YYYY
Use the "Add" button to add additional Meds and OTCs for each Rx or OTC.

Per NJY camps policy no gummy medications are permitted. Acceptable forms are chewable, dissolvable, tablet, or capsule.
Medication Strength Dose Form/Type 1st Dose 2nd Dose 3rd Dose Frequency Dosing Instruction Details eRx? Actions

Please Review the Following

• If your child’s physician is prescribing medication via electronic prescriptions or faxing hand written/signed prescriptions, please provide the physician with the information below.

• Control 2 (C2) prescriptions must be written in 30-day quantities due to insurance restrictions. Physicians can write for several months at a time by noting on the Rx when it can be filled, i.e. “Do not fill before MM/DD/YYYY”. Hand written C2 Rx’s should be faxed and then the hard copy sent in the mail directly to Keystone Professional Pharmacy (information below).

• If you are sending medication to Keystone Professional Pharmacy for repacking, please use the address below and send in C/O Rosemary Spiccioli:

Keystone Professional Pharmacy C/O Rosemary Spiccioli
485 South River Street
Wilkes-Barre, PA 18703
Phone: (877) 970-2200
Fax: (877) 970-2205
NPI#: 1255443263

Any questions or concerns should be addressed directly to Keystone Professional Pharmacy at 570-970-2200 ext 3 (ask for Rosemary or Karen) or email
Please Review and Check the Following Items:(Required)
Please upload All Listed Prescriptions UNLESS electronically prescribed
Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 64 MB, Max. files: 10.
    Please enter a number from 0 to 10.