Medication Refill Request [RC]

Psychiatric Medication Refill Request

Use this form to request a prescription medication refill. If you experience any issues with your submission, please email medrefills@responsivecenters.com. Our team will respond to your inquiry during business hours.
How do refill requests work?

This form must be completed by the client, the client’s provider, or an authorized caregiver. Responsive Centers will process valid requests within 48 business hours or contact the client if additional information is needed. If you are a new client seeking medication management services, please visit https://responsivecenters.com to request an initial evaluation.
Client's Full Legal Name*

PrefixFirst NameMiddle NameLast NameSuffix
Client's Date of Birth*

MonthDayYear
MM-DD-YYYY
Please enter the name and dosage for each medication being requested.*
Pharmacy Name*
E.g., CVS
Please enter the pharmacy location where this medication will be picked up.*

Street Address (Required)

Street Address Line 2

City (Required)State

Zip Code
Please add any additional information here.
Are you the client?*

YesNo
Name of Individual Requesting*

First NameLast Name
Relationship to Client*
HIPAA Acknowledgement

Clients have certain rights to privacy regarding their protected health information under the HIPAA Act. By checking the box above and submitting this form, the client is acknowledging that they may voluntarily be sharing sensitive information with our practice. While Responsive Centers cannot guarantee confidentially, we will never share any sensitive information with unknown third-party entities or use it for purposes outside of intake and scheduling. Please review our complete Privacy Policy here: https://responsivecenters.com/privacy-policy.php.
Date*

MonthDayYear
Today's Date
Initials*
Should be Empty:

Psychiatric Medication Refill Request

How do refill requests work?

HIPAA Acknowledgement