Step 3b: Keystone Professional Pharmacy - NJY Add/Change Medication Form The medication changes you enter below will only apply to the individual child you specify below. You will need to fill out this form for each child that has a change in their medicine. Please read the following instructions and then fill out your child's prescriptions and OTCs in the form below. IT IS VERY IMPORTANT THAT YOU FILL EACH COLUMN ACCURATELY. Parent’s instructions on the medication form must match the prescriptions. The most common discrepancies are: GENERIC vs BRAND DAILY vs AS NEEDED 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.Add/Change Individual Child Medication and OTC FormChild Name(Required) First Middle Last Child DOB(Required) MM slash DD slash YYYY Prescription Meds & OTCs to be Dispensed by Keystone Prof PharmacyUse 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 Actions Edit Delete There are no Meds & OTCs. Add Meds & OTCs Maximum number of meds & otcs reached. 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 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 info@kppmeds.comPlease Review and Check the Following Items:(Required) I am aware that the prescriptions listed above must match the prescriptions sent to Keystone. Carefully review all written prescriptions to ensure they are IDENTICAL to your list above. If not, contact physician for a new RX or correct your list prior to sending to Keystone Pharmacy. I am aware that all medication is dispensed as GENERIC unless the PRESCRIPTION clearly instructs "BRAND NAME NECESSARY." You may incur a higher co-pay from your insurance carrier for a brand name drug. I am aware that medications ordered AS NEEDED/PRN will ONLY be refilled when requested. Please Upload Hand Written/Signed PrescriptionsPlease upload All Listed Prescriptions UNLESS electronically prescribed Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB, Max. files: 10. Total Number of Prescriptions Enclosed (Uploaded)(Required)Please enter a number from 0 to 10.
