Psychiatric Medication Refill Request
Use this form to request a prescription medication refill. If you experience any issues with your submission, please email medmamagement@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.
** Important Notice **
If you are requesting a controlled substance, you must have had an appointment within the past 90 days. If you have not, please contact our office to schedule a follow-up visit. Refills will not be filled until this requirement is met. To schedule a follow-up please call 913-451-8550 ext 101, you can type extension at any time, or contact use via email at medmamagement@responsivecenters.com
Client's Full Legal Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Client's Date of Birth
*
-
Month
-
Day
Year
MM-DD-YYYY
Phone Number
*
Should we have any questions about your medications
Format: (000) 000-0000.
Please enter the name and dosage for each medication being requested.
*
Stimulant Medication Type
*
Please Select
Extended Release (XR)
Instant Release (IR)
N/A
If you are requesting a refill for a stimulant medication, please select the type below. If your medication is not a stimulant, select N/A.
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)
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please add any additional information here.
Are you the client?
*
Yes
No
Name of Individual Requesting
*
First Name
Last 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
*
-
Month
-
Day
Year
Today's Date
Initials
*
Continue
Should be Empty: