Mental Health | Monarch Mental Health And Wellness

Medication Refill Request

It is our office's policy that medication refills will only be provided at regularly scheduled psychiatric follow-up visits. Please contact your pharmacy first and confirm any remaining refills. This form is intended urgent medication refill requests, only such as situations in which a patient will run out of medication shortly before a scheduled office visit or situations in which an emergency prevents a patient from attending a scheduled office visit.

Before submitting your request:

Please contact your pharmacy first to make sure that you don't have any refills remaining on the last prescription(s) provided by your provider at our office. Our office is available to respond to medication refill requests during administration hours, Monday-Thursday 10am-4pm, and Friday 10am-12pm. The length of time needed to process to your request once received is typically within 2 business days. To ensure same-week processing, please submit requests Monday through Wednesday. Requests made after 12PM on Friday, weekends, holidays, and/or when our office is closed, will be received the next business day. Please note, refills are not processed outside of business hours, on weekends, or holidays. If you need a medication refill during that time, please visit your nearest ER or urgent care center.

Medication Refill Requests May Be Denied If:

You do not have a psychiatric follow-up appointment scheduled
You have not been seen for an office visit in over 1 year.
You frequently miss or cancel appointments at our practice.
You have an outstanding balance for services received at our practice.
Medications may not be given if you cancel or no-show regardless of the dangers associated with abrupt discontinuation if the doctor feels a clinical evaluation is necessary prior to a refill.

Please see "Medication / Prescription Refill Policy" in FAQs for more information.

First Name

Last Name

Date of Birth required

Phone Number

Email Address

Date of Next Appointment required

Pharmacy & Phone Number

Medication Name(s) & Dosage

Option: Upload Photo of Medication(s)

I have contacted my pharmacy first and confirmed I don't have any remaining refills.

I have a psychiatric follow-up appointment scheduled.

I do not frequently miss, cancel, or reschedule my appointments.

I do not have an outstanding balance on my patient account ( found in MYIO Patient Portal ).

I have been seen by my provider within the last year ( if prescribed controlled substances, I have been seen by my provider within the last 3 months ).

By submitting this Medication Refill Request form, you agree to have Monarch Mental Health & Wellness contact you by our HIPAA compliant text/phone line or by email.

Thank you for submitting!

Please see our "Medication / Prescription Refill Policy" in FAQs for more information. Once submitted and received, refill requests are processed within 2 business days.

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