Med Mgmt Refills.2022.v1

To request a refill of your medication, please start by answering the question below:

Do you have any type of government insurance (i.e., Medicare, Medicaid or Tricare) either as a primary or secondary policy?*

YESNO

I have COMMERCIAL INSURANCE only (examples: United Health Care, Humana, Anthem) and I have paid the $50 fee for the E-prescribing convenience service?*

YES, I have paid the $50 e-Prescribing feeNO, I have NOT paid the $50 e-Prescribing fee

Medication refill requests are contingent upon review and approval by the medical staff. This is not a guarantee that your request will be fulfilled.

Name*

First NameLast Name

Date of Birth*

Your Birthday!

Birthdate

Confirm Your Date of Birth*

Date of Birth

Confirm Birthdate

Verification

Cell Phone #*

Please enter a valid phone number.

Email

example@example.com

What medication would you like to refill?

If you have our E-prescribing service, then your prescription will be available at your pharmacy AFTER 2 business days. E-prescribing is a convenience and security service that is not covered by your insurance company, and the cost of this convenience and security service is $50 every 6 months.

As always if you have an account balance, payment of that account balance is required prior to services being rendered. Coinsurance and deductibles apply, though some healthcare providers are reducing or waiving the amount you pay for telehealth visits. Medication refill requests are contingent upon review and approval of the medical staff.

FROM THE CALENDAR BELOW, PLEASE REQUEST YOUR MEDICATION MANAGEMENT TELEPHONE APPOINTMENT TIME AND WE WILL CALL YOU DURING A TWO HOUR WINDOW STARTING AT THAT TIME.

Request Your Appointment*

calculation

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REFILL MY MEDICATION