Medication Refill Request Form
Complete this form to request a medication refill. Please allow 24 hours for processing.
Please note, refill requests submitted after noon on Fridays will not be processed until the following business day (Monday or Tuesday if Monday is a holiday).
BEFORE COMPLETING THIS FORM, PLEASE CALL YOUR PHARMACY TO SEE IF THERE IS A REFILL ON FILE AVAILABLE TO YOU. IN ABOUT 85% OF CASES, PATIENTS HAVE A REFILL WAITING AT THE PHARMACY THAT COULD BE FILLED, IF REQUESTED. CALLING THERE FIRST WILL SAVE YOU TIME. THANKS!
Have you called your pharmacy to see if a refill is available to be filled?
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This form was created inside of Providers for Healthy Living, LLC.