Atlanta Area Family Psychiatry Clinic, P.C. ~ Rx Refill Request-2

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Rx Refill Request

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Rx refill by FAX

For best practices, it is preferred that you request refills for medication(s) while in your appointment so that your physician may monitor your care and adjust your prescription accordingly. As an accomodation to those who can not make a timely appointment, we offer this form to request refills until you can see your provider.

Many pharmacies send automated refill requests to us in hopes that you continue to use their pharmacy and that you don’t miss a refill. This may lead to medication errors if your medication or dose has been changed in the interim. We do not respond to those requests and ask that you submit refill requests here instead.

This form is for you to request a refill outside of an appointment.

Please allow THREE FULL BUSINESS DAYS for completion of your request.

Also note that some mail-in pharmacies take up to two weeks to fill your prescription.

All of our Physicians now ePrescribeand ALL PRESCRIPTIONS are now transmitted electronically directly to your pharmacy. (We no longer mail out or hand write prescriptions. Our software allows for better prescription managment and side effect monitoring.)

You MUST provide your pharmacy address, telephone number, and ZIP CODE for ALL prescription requests.

Also note: All Prescriptions filled outside of an appointment will be charged $25 or

$45 for expedited requests. Rx refill charges will be entered in your Luminello account by your provider.

# = required field

Atlanta Area Family Psychiatry Clinic, P.C.

Psychiatric and psychotherapeutic care for adults, children, adolescents and families

since 1977

 Your Prescription Information:

Select your physician, REQUIRED! SCROLL down: #

Your name if diferent from patient:

Patient's First name: #

Patient's Last name: #

Medication #1 (get name from bottle if not sure): #

Med #1 Dose (mg); #

Med #1 Directions: #

Med # 1 Quantity: #

Medication #2 (get name from bottle if not sure):

Med # 2 Dose (mg);

Med # 2 Directions:

Med # 2 Quantity:

Medication #3 (get name from bottle if not sure):

Med # 3 Dose (mg);

Med # 3 Directions:

Med # 3 Quantity:

Medication #4 (get name from bottle if not sure):

Med # 4 Dose (mg);

Med # 4 Directions:

Med # 4 Quantity:

Comments:

Last Appointment Date: #

Your e m a i l: #

Your preferred contact (xxx) xxx-xxxx: #

Pharmacy Information:

Pharmacy NAME & Address: #

City: #

State: #

ZIP: #

Telephone: #

Is this a DIFFERENT pharmacy from last request? #

CHECKOUT

NOTE: ALL Rx Charges are now entered in LUMINELLO by your provider.

(PayPal is deactived for Rx's)

Note: A Luminello portal is not required to request a Rx. It will still be needed though for you to access billing records and.enter billing information.

Step 1: ALL Rx requests: After filling out fields above, , select Rx refill handling fee,

"Outside of appointment, $25 (allow 3 FULL BUSINESS DAYS)"

or #

"Expedited Handling, rapid service $45"

Expedited Rx's are transmitted the same business day.

(If request is received after 12 NOON, Rx will be transmitted the next business day.)

Select "Outside of appointment $25 fee" or "Expedited handling $45"

Note: These fees are one time for all Rx's requested this day, not for each Rx.

Step 2, ALL Rx REQUESTS: You MUST click "Submit" AFTER completing form to finalize your request to AAFPC.

ALL REQUESTS, click SUBMIT: #

Rx fees are entered by your provder in Luminello.

All requests are handled by secretary.

No Rx's are filled if office is closed.

Please CALL your pharmacy to confirm your Rx has been filled before calling us.

(Many pharmacies are inefficient in sending filled notifications.)

We do not contact you to notify you if your Rx has been sent.

Allow three business days for fulfillment unless expedited.

Atlanta Area Family Psychiatry Clinic, P.C.

7000 Peachtree Dunwoody Rd, Building 16 Suite 100 ~ Sandy Springs, GA 30328

Telephone (770) 393-1880 ~ Facsimile (770) 393-1885

NOTE: We are still having problems with our web host email system not forwarding all emails to us. Most, but not all, get through. Very frustratiing for you and your prescriber as well.

We are working on moving this service to a new host but that will take some time.

In the mentime, if your pharmacy hasn't verified your Rx has been received within 3 days of request, please call the office and request it be sent to your prescriber again (770) 393-1880 ext "0".

We apalogize for this inconvenience although it is beyond our control for now.

SELECTION

REQUIRED

Please NOTE:

This form is no longer active. Please click here to go to www.AAFPC.net and navigate to our new and improved Rx refill request page.

Thank-you