Automatic Refill Program Change Request Form

Automatic Refill Program Change Request

Please use this HIPAA-secure form if you are a patient who has a prescription enrolled in the Automatic Refill Program and would like to submit a change or cancellation request.
Patient Name*

First NameMiddle NameLast Name
Patient Email*
If patient is a minor, use parent / guardian email. example@example.com
Patient Date of Birth*

MonthDayYear
Date
Rx Number*
Enter your Prescription Number found on the label of your medication.
Medication Name
Type the name of the medication.
Person Filling Out This Form*

First NameLast Name
Relation to Patient*
change the date of my next automatic refill.change my shipping address.change my credit card information.withrdraw / cancel my automatic refill on this prescription.Other
You selected that you would like to change the date of your next automatic refill. Please select the new date that you would like to RECEIVE your next prescription refill. We will ship it prior to this date, provided that it is not too early to refill your prescription. We cannot accommodate deliveries to arrive on weekends or federal holidays.

Please note: Your automated refill dates are calculated automatically by the last fill date plus the day supply to ensure the continuity of your medication. If you are changing your next refill date due to still having medication left over from your last refill, please be sure to check the beyond-use date (BUD) and all advisory stickers on your medication. We do not recommend using any compound medication past the beyond use date or the time frame dates indicated in any advisory, whichever is earlier. Should you have any questions, please contact us to speak with a pharmacist.
Date Change for Next Automated Refill

MonthDayYear
Date
You selected that you would like to update your credit card. To maintain payment compliance industry (PCI) standards, we will need to call you to update your credit card information. Please submit this form so we know that you have a credit card change.
I am going on vacation or out of town at the time of my next automated refill.I still have medication left over and within the BUD.Cancel Reason: I am no longer taking this medication and have a new prescription.Cancel Reason: I am no longer on this treatment plan and do not have a new prescription.Other
You selected that you would like to update your shipping address. Please note: We can only ship to states that we are licensed in. You can see this list on our States We Serve page. We can only ship sterile compounds, which include Atropine Sulfate Ophthalmic Solutions, in California. No exceptions can be made to this policy as it is a board of pharmacy regulation.
Update Patient Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The Automatic Refill Program is a free-of-charge service for patients requesting medications to be filled on a regular time interval to prevent delays and interruptions to therapy.

Enrollment in the Automatic Refill Program is on a per-prescription basis, not per patient. If your prescription runs out of refills, the refill authorization from your doctor, even if for the same medication, is considered a New Prescription and you will be provided with a link to pay and an option to (re)enroll your new prescription into the Automatic Refill Program.

IMPORTANT: NO CHANGES OR REFUNDS CAN BE PROCESSED ONCE YOUR PRESCRIPTION HAS BEEN DISPENSED AND SHIPPED, UNLESS YOU PROVIDED NOTIFICATION OF CHANGES OR WITHDRAWAL FROM THE PROGRAM PRIOR TO YOUR PRESCRIPTION BEING DISPENSED AND SHIPPED.

For more information, please see the Automatic Refill Program Notice on our website.
Any additional information you would like us to know?
Thank you for completing this form. You may electronically submit the automated refill change request notice to Valor Compounding Pharmacy by clicking "Submit" below. A Customer Care Specialist Services Representative will follow-up shortly.
Please verify that you are human*
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