Prescription Request

Prescription Request

Patients must be seen once every 90 days in order to request a medication renewal.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Who is your prescriber?
Prescriber Mojo Email
example@example.com
Prescriber Ann Arbor Psych Email
example@example.com
What is the soonest you will run out of any of your meds?

Already ran out1 day2 days3 days4 daysa week2 weeks or more
Please read and check off all to progress.

Thanks for using this form, it'll go directly to your prescribers inboxYour Gmail hides our email responses to these requests, and also to any voicemails you leave when calling. (see screenshot below of where emails get hidden)Reveal our emails by searching "Ann Arbor Psych" in Gmail (give us at least 24 hours to respond).Please request scripts at least 3 business days before they expire, as turn around time varies from 24 to 72 business hours, depending on the type of prescription.Sorry, we are unable to respond to automatic pharmacy requests/faxes for renewals, due to the volume of inaccurate requests. Please use this web form for a fast response!If the pharmacist tells you your prescription requires a prior authorization to be filled, let us know by filling out this form https://form.jotform.com/220354174876056To be clear: this is a place to request a renewal of a medication at a dose you are already on, if changes or new medications are required then an appointment is needed to discuss
Do you have a follow up appointment? If so, let us know when. A follow up appointment is something we need to send meds, so if you do not have a follow up appointment already, use the link after this question to make one and let us know what date you made it for.
We cannot renew medications without a follow up appointment. If you don't have one, click the link below and select your prescriber.
Schedule with prescribers: https://annarborpsych.com/prescribers-2/

1st Medication
1st Medication
Medication 1*
As written on bottle
If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.*
What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
How many days (30 vs 90) does this refill need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
Dose from bottle*
This is necessary to avoid medication errors
How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?*
Have you run out of this medication? If so how long has it been since you took it regularly?*
If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
When will you run out of this medication?*
Given that enough medications are prescribed to last until next appointment, why is this request needed?*

Ann Arbor Psych moved or cancelled my initial appointmentI moved or cancelled my initial appointmentI missed the call after my appointmentI have to change which pharmacy the medication is being sent toYou contacted me about a error in your systemType any other answers here
Which pharmacy is this script going to? (Name of pharmacy, city, street)*
If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular

2nd Medication
2nd Medication
Medication 2
As written on bottle
If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.
What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
How many days (30 vs 90) does this refill (medication 2) need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
Dose from bottle
This is necessary to avoid medication errors
How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?
Have you run out of this medication? If so how long has it been since you took it regularly?
If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
When will you run out of this medication?
Given that enough medications are prescribed to last until next appointment, why is this request needed?

Ann Arbor Psych moved or cancelled my initial appointmentI moved or cancelled my initial appointmentI missed the call after my appointmentI have to change which pharmacy the medication is being sent toType any other answers here
IMPORTANT!!! Which pharmacy is this script going to? (Name of pharmacy, city, street)
If we have never prescribed to this pharmacy for you, we need the full street address and city in order to disambiguate.
If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular

3rd Medication
3rd Medication
Medication 3
As written on bottle
If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.
What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
How many days (30 vs 90) does this refill (medication 3) need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
Dose from bottle
This is necessary to avoid medication errors
How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?
Have you run out of this medication? If so how long has it been since you took it regularly?
If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
When will you run out of this medication?
Given that enough medications are prescribed to last until next appointment, why is this request needed?

Ann Arbor Psych moved or cancelled my initial appointmentI moved or cancelled my initial appointmentI missed the call after my appointmentI have to change which pharmacy the medication is being sent toType any other answers here
Which pharmacy is this script going to? (Name of pharmacy, city, street)
If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular

4th Medication
4th Medication (Phew! Almost done!)
Medication 4
As written on bottle
If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.
What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
How many days (30 vs 90) does this refill (medication 4) need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
Dose from bottle
This is necessary to avoid medication errors
How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?
Have you run out of this medication? If so how long has it been since you took it regularly?
If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
When will you run out of this medication?
Given that enough medications are prescribed to last until next appointment, why is this request needed?

Ann Arbor Psych moved or cancelled my initial appointmentI moved or cancelled my initial appointmentI missed the call after my appointmentI have to change which pharmacy the medication is being sent toType any other answers here
Which pharmacy is this script going to? (Name of pharmacy, city, street)
If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular

Submit
- Ocassional fees:
  - There is never a prescription fee if there is a clinician or pharmacy error. Please indicate so when asked why medication is being requested.
  - Regarding prescription fees:
    
    The regular 20 dollar prescription fee is waived if a patient has been seen within the last 3 months.
    
    For controlled substances -- which are medications considered drugs of abuse by the DEA -- there is an additional $20 prescription fee.
    
    This is to account for legally mandated time consuming steps taken by prescriber each time a controlled substance is prescribed.
    
    Controlled substances include Ritalin, Adderall, Concerta, Neurontin, Vyvanse, Xanax, Klonopin, and Ativan.
Should be Empty: