Request for Medication Refill.. | David Scott May, MD

PLEASE READ THIS CAREFULLY AND FILL IT OUT CAREFULLY

Patient First Name

Patient Last Name

Date of Birth

Patient Phone Number

Patient Email

Patient Address

Number of Medications requested:

(use a second form for 4+)

Is the pharmacy for this refill the same as the last one used?

Yes

Pharmacy Name for this refill

Pharmacy phone for this refill

(REQUIRED FULL PHARMACY ADDRESS AND ZIP CODE) Pharmacy Address including Zip Code for this refill

Notes for Dr. May:

Please comment on how you feel the medication is working for you currently. If you are requesting a change or have a question, please include that in this section.

MEDICATION 1

Specific Medication Requested

(Expensive) Brand Name or (Equivalent) Generic?

(look on your pill container if you are not certain)

Is this a stimulant?

Milligram (Mg) Strength

Number of times used each day

Number of Pills in total requested

Number of refills requested

(none allowed by law for stimulant medication)

Additional Information:

All refills will be sent in electronically within 48 hours and typically within 24 hours. If your pharmacy says the Rx was not received by 48 hours send me an email at davidscottmay@mac.com and send me a second request.

There is no charge when filling a Rx request during a Zoom face-to-face session. Because recording and authorizing your medication requires a fair amount of time when you are not present, I charge $60 for up to 4 months of a non-stimulant medication refill.

Because stimulants are a controlled substance, they require monthly renewals, extra security as well as double authentication. For each month of a refill of a single stimulant there is a charge of $60 and if there is a second stimulant (medication) at the same refill then there is a total charge of $70 for the two.

Remember, once I have prescribed a medication, if it’s not covered by insurance, you can pay for it out of pocket even if the pharmacy say’s a prior authorization is required. Your insurance may insist on a Prior Authorization approval before they will be willing to cover the cost for 12 months of a specifically requested medication, especially for brand name medication. Because getting a Prior Authorization can take considerable time to fill in elaborate clinical justification criteria and can save you thousands of dollars over 12 months, I charge $140 for my time involved processing it.