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. Once I have filled your medication request, you will get an email signed by me telling you it has been sent in by me.

If your pharmacy says the Rx was not received by 48 hours send me an email at davidscottmay@mac.com and also submit a second medication request at www.davidscottmaymd.com

Because recording and authorizing your medication requires a fair amount of time when you are not present at a session, I charge $60 for non-stimulant medication with 3 refills.

Because stimulants are a controlled substance, California requires monthly renewals, extra security as well as double authentication. For each month of a refill of a 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.

If your medication is not covered by insurance or the pharmacy says you need a prior authorization, you can still pick it up by paying out-of-pocket for it. Should you want me to appeal for a prior authorization where it can potentially be covered for 12 months, there is a modest charge for the extended time it takes to meet the clinical justification requirements of your insurance company. To initiate this please email me at davidscottmay@mac.com