• MEDICATION REFILL REQUEST

    Use this form to request medication refills for Transitional IOP Level of Care through the Medication/Medical Department.

  • I. MEMBER DEMOGRAPHICS

  • c. Member Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • e. Insurance of Member: AHCCCS or Other -
  • f. Are you allergic to any medications?

  • II. MEDICATION INFORMATION

  • INSTRUCTIONS: Please choose one of the following options to provide your medication refill details.

    Option 1: 

    Upload or Take a photo or of your medication bottle or bubble pack: capturing all necessary details such as the medication name, refill date, quantity, and purpose.

    • A- Use the 'Take Photo' widget button to capture a clear image of your medication bottle or bubble pack directly through this form.
      Or,
    • B- use the 'File Upload' button to upload an existing photo from your device. You can take a photo with your phone APP and then choose to upload.

    📸 Photo Instructions:

    • ✔ Place the bottle on a steady surface for a clear, readable image.
    • ✔ Do not hold the bottle in your hand while taking the photo.
    • ✔ You can submit multiple photos for additional medications

    DONT FORGET TO FILL OUT THE NEEDED INFORMATION NOT INCLUDED IN PICTURE ON TABLE BELOW: 

    • 1. Medication Name
    • 4. Refill Needed By
    • (as needed) 5. Additional Comments
       


    		 OR

    Option 2: 

    Fill Out the Medication Refill Table completely and manually.

    Complete the table below with details about each medication you need refilled, including Medication Name, Dosage, Frequency, Purpose, and Refill Needed By.

     

     

     

     

     

     

     

     

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    Please select the method that is easiest for you. If you take a photo, you only need to provide minimal details in the table.

  • 1. OPTION #1

    A- Take Photo button OR B-File Upload (take picture with your camera and then upload)
  • OPTION #1 A: Take Photo – Use the Photo Widget to capture a clear, in-focus image of the medication bottle needing a refill. Ensure the label details are readable. You may take multiple photos if needed.
  • Upload Medication Photo: Take a picture with your phone and upload it here.
    Drag and drop files here
    Choose a file
    Cancelof

  • 2. OPTION #2 - Manual Entry:

  • A. MEDICATION REFILL REQUEST TABLE: Find Details (Name, Dosage, Frequency, etc.) on Your Prescription Bottle or Bubble Pack.
    Rows

  • Confirmation and Signature:

    Please read and sign! thank you for participating in your recovery today!

  • As a vital part of my treatment journey, I acknowledge and embrace the responsibility of managing my medications diligently. By actively participating in the timely request of medication refills, I am taking an essential step towards self-care and recovery. This process is crucial not only for my health but also for maintaining the progress I make every day. I understand that managing my medication effectively is a fundamental part of my overall wellness and a direct reflection of my commitment to my healing process.

    I hereby confirm that the information provided above is accurate and complete to the best of my knowledge. I commit to following the prescribed guidelines and to communicating openly with my healthcare providers about my medication needs and any challenges I encounter along the way.

  • Date of Signature & Request:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: