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Refill Request
Refill Request
If you are in need of a medication refill, please complete this form. 
15Questions
Refill Request
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     Welcome!

    We use this form to collect information to help us process your refill request quickly and convieniently. Please note this form is for refills only. If you are experiencing a medicaiton concern or are wanting to to make changes to your medicaiton please contact our office by phone. 

    This form is HIPPA compliant; any information entered into this form is stored and saved securely and will be used for the purpose of evaluating your medication request.

    Please note that a $15.00 medication refill fee for evaluation and management of prescriptions via telephone, text, portal, or email due to missed, cancelled, or unscheduled follow up appointments may be billed to your patinet account. This fee is not covered by insurance.

    This form inbox is monitered deligently during our business hours (Monday-Thursday 8:00am-4:00pm and Friday from 8:00am-12:00pm; excluding holidays). If your request is made outside our normal buisness hours it will be addressed on the following buisness day. If your request is urgent please call our office number 334-954-6010 and leave a voicemail with detailed information regarding your request. 

    To proceed in completing this form click the next button below.

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  • 4
    Please specify the medication name and dosage.
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    If you have not called your pharmacy please do call them to see if there is medication available for pick up even if it says no refills on the bottle of your medicine. Often when a 90 day supply of medication is called in the pharmacist will only fill 30 days at a time for insurance purposes. There also could be an unfilled prescription waiting for you at the pharmacy. 

    Once you have called your pharmacy and verified there is no medicaiton available to you you can resume this form where you left off.

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    If you have seen multiple providers at our practice please select the provider with whom you had your last appointment
    • Dr. Amanda Williams
    • Dr. Will Rutland
    • Rachel Liner, CMHNP
    • Thomas Earnest, CMHNP
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    It is essiential you are evaluated regularly when taking medications. For this reason, please be advised you may need a follow up appointment scheudled in order for your provider to call in your medication. Someone from our office will give you a call regarding scheduleing if that is the case.

    You may proceed in completing this form by clicking the next button below. 

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