Refill Request

ATTENTION: PLEASE READ BELOW BEFORE MAKING A PRESCRIPTION REFILL REQUESTS

This form is for existing patients to request prescription refills.
Refills may take up to 48 business hours to process.
(The office is closed Sunday & Monday)

Medications requiring prior authorizations do take longer (up to 5 business days) to process. Pharmacies are responsible for sending the Authorization request, if we DO NOT receive the request, we don’t/won’t know you need one. PA’s are done electronically and NEVER called in.
We may need to contact you regarding your request.
Paper (hardcopy) prescriptions will be given to patients for mail order refills and controlled substance medications.
We will deny certain requests without an office visit to adhere to DEA guidelines.

Refill Request

Name*
First Last
Date of Birth*
Your Provider*
- Bartczak
- Davidson
Phone*
Email*
Name of Medication*
Strength*
How often do you take it?*
Pharmacy Name*
Pharmacy Phone*
Pharmacy Address*
Mail Order Pharmacy?*
- Yes
- No
By selecting yes, you agree that a hardcopy (paper) prescription will be issued. We will notify you when ready for pick up; prescriptions left at the front desk for longer than two (2) months will be discarded. It is the patient's responsibility to submit refills to mail order pharmacies.

New Prescriptions

Please call to make an appointment if you are requesting new medication prescription that one of our physicians has not provided previously.

Prior Authorizations

Prior authorizations are being increasingly required by insurance carriers. In an effort to control costs, carriers necessitate that physicians provide “proof” that patients need certain medications. This is usually done through supplemental forms, labs or additional phone calls. The end result, unfortunately, may be a denial or longer wait time for a medication. We realize this can be frustrating for our patients, but the extra time required for these processes is tremendous. As we try to assist everyone with their individual medication needs, please be patient if your particular drug requires prior authorization.

Controlled Substances

Pursuant to Florida State Legislative Bill CS/CS/HB 7095 (effective July 1, 2011), our physicians can no longer write prescriptions for certain controlled substances. If you need pain medications, you will be referred to Pain Management. These rules apply to NEW and EXISTING patients. If you have any questions about these rules, please speak with your doctor.