Prescriptions and Medications Form

Step 3: Keystone Professional Pharmacy - Student Medication Form

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.
NO MEDICATIONS WILL BE FILLED WITHOUT THE MED FORM BEING COMPLETED BY THE PARENT.

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.

PLEASE NOTE that Keystone Pharmacy does not fill Inhalers, EpiPens, Injectables, Growth Hormones, Birth Control Prescriptions, or Acne Meds topicals and gels. Parent will be contacted if Keystone is unable to fill medication.

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)
All prescriptions should be sent electronically.

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.

Individual Child Medication and OTC Form

Email of Parent(Required)

(to receive email confirmations for this form only)

Child Name(Required)

First Middle Last

Child DOB(Required)

Prescription Meds & OTCs to be Dispensed by Keystone Prof Pharmacy

Use the "Add" button to add additional Meds and OTCs for each Rx or OTC.

Medication	Strength	Dose	Form/Type	1st Dose	2nd Dose	3rd Dose	Frequency	Dosing Instruction Details	Rx or OTC	eRx?	Actions

There are no Meds & OTCs.

Add Credit Card for Medication Costs(Required)

Add a credit card to cover medication costs, co-pays, deductibles, or repack fees. Repack fees are $15.00 per med. Keystone will securely store your Credit Card information. In case of non-payment of co-pays, deductibles, repack fees, otc fees, and any other applicable medication fees, your credit card will be charged as necessary.

Credit Card Expiration Date(Required)

Credit Card Security Code(Required)

3 Digit (on back of most cards) or 4 Digit (American Express on front) Security Code

Credit Card Billing Address(Required)

Enter the credit card billing address for the card you would like used for Medication Costs.

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.
MUST BE SENT WITH SIGNATURE REQUIRED:

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 or info@kppmeds.com

Please 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.

I am aware that registration fees are separate from medication costs, co-pays, deductibles, or repack fees. Repack fees are $15.00 per med. Keystone will securely store your Credit Card information. In case of non-payment of co-pays, deductibles, repack fees, otc fees, and any other applicable medication fees, your credit card will be charged as necessary.

Please Upload Hand Written/Signed Prescriptions

Please upload All Listed Prescriptions UNLESS electronically prescribed

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 12 GB, Max. files: 20.

Total Number of Prescriptions Enclosed (Uploaded)(Required)

Please enter a number from 0 to 20.