Routine Medication Refill Request Form
If you need a refill of your current medications before your next appointment, you may use this form to give our staff the information they need to process your request as soon as possible during the business day.
Be advised that use of this form does not guarantee you will automatically receive every medication you request. It also does not promise the pharmacy will have it filled promptly. Your insurance may also require a Prior Authorization.
  Note: Do not use this form if:
  1. You suspect a medication is causing side effects and/or wish to ask for dose adjustments. This needs to be discussed with your prescriber or with the Nurse.
  2. You wish to discuss changing to a different medication. This can only be reviewed and approved by your prescriber.
  3. If you are leaving our care, you will want to ask for a transfer to the Medication Management Desk for a “follow up appointment exception and medication bridge”.
In any of these situations, please call 480-471-8560, option “medication issues”.

NOTE: Before authorizing a refill for a controlled substance, best medical practices require prescribers to evaluate the patient at an appointment first. To get an appointment, please call 480-471-8560 and select option 3.
When this form is completed appropriately, you should receive a call from your pharmacy within 2-5 days to notify you your meds are ready.  You will only receive a call back from our staff if we are encounter have a problem or question.
     Patient Information:  
               First name:  
  Last name:  
  Birth Date:  
   Date of next appointment:    With which prescriber: 
(remember our therapists and counselors cannot manage your medications so you will only see prescriber names)
     Is this the same provider who gave you this medication last time?
               Yes:       No: 
      Are there any changes in the patient's drug allergies?
               Yes:       No: 
      Which Pharmacy should the prescription be sent to?
The SAME pharmacy as in my file:      Different pharmacy:
     Medication Requested
Enter the Medication Name:
If you aren't sure about the exact spelling of your meds, enter what you know so the smart search can find it. Either brand name or generic words will work. Please do not enter a medication our providers have never prescribed for you before (for new meds call for an appt 480-471-8560)
How Do you take this medication?
Take Regularly   Take only as Needed
     The medicine formula is:    
     Medicine strength (such as 0.25mg or 300mg) the best you can recall.
Medication strength
Other strength. Enter if you have two strengths of the same medication and need both
If you're not sure about the strength, the following question will help us find it in your record.
Were there any recent changes in the strength of your med?   Yes, it has changed   No, it has not changed
     How many days supply do you have now?    
     Information for the person submitting this form:
Are you:   The Patient     or    Parent or Family member
What is the best phone number or email to contact you for questions?
If this is a phone with a generic message, may we identify our call as a “physician's office calling about medication”?
   Yes, that is ok    No, please just say the message is for me and leave Redemption contact name and number.
     If you need another refill please submit another form by clicking the link on the next page...

Thank you for using this method to request your medication. This will allow our nurses to address more urgent patient concerns (such as illness, side effects, or pharmacy/insurance med problems)

American Academy of Child & Adolescent Psychiatry    American Psychiatric Association