Prescription Refill Request Form Template
Let patients request prescription refills online, reducing wait times at pharmacies and improving medication compliance.
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What is a Prescription Refill Request Form?
A prescription refill request form allows patients to request medication refills from their healthcare provider online instead of calling the pharmacy or office. It captures medication details, patient information, and pharmacy details needed to process refills efficiently.
Online refill requests reduce pharmacy wait times, improve medication adherence, and reduce phone volume for healthcare offices. Patients can request refills at any time, improving convenience and medication access.
Electronic refill requests integrate with pharmacy systems (via NCPDP standards) and EHR systems to automate processing. Many healthcare systems now expect refill requests through patient portals for routine medications.
Key Features
Medication Details
Captures medication name, dosage, and prescription number
Pharmacy Information
Records patient pharmacy preference for refill delivery
Refill Quantity
Specifies number of refills needed
Urgency Priority
Allows marking routine vs. urgent refill requests
Request Reason
Notes section for special circumstances
Integration Ready
Designed for EHR and pharmacy system integration
Why Use This Template?
Improved Medication Access
Patients can request refills anytime without calling office
Better Compliance
Easier refill process reduces missed doses and improves adherence
Reduce Phone Volume
Online refill requests reduce prescription-related phone calls to offices
Faster Processing
Electronic requests integrate with EHR and pharmacy for quick processing
What's Included in This Template
Patient Name & Date of Birth
textIdentifies patient for prescription verification
Medication Name
textIdentifies the prescription needing refill
Dosage Strength
textSpecifies correct dose for refill verification
Prescription Number
textEnables pharmacy to locate and refill specific prescription
Pharmacy Name & Phone
textRoutes refill to patient's preferred pharmacy
Number of Refills Needed
selectSpecifies quantity of refill bottles requested
Is this urgent?
selectPrioritizes processing of urgent refill requests
Additional Notes
textareaCaptures special requests (brand vs. generic, location, etc.)
Perfect For
Primary Care Clinics
Allow patients to request medication refills between visits
Specialty Practices
Manage prescription refills for chronic disease medications
Patient Portals
Integration with EHR patient portal for online refill requests
Telemedicine Providers
Process refill requests without requiring patient visit
Frequently Asked Questions
How quickly should refill requests be processed?
Routine refills: 24-48 hours. Urgent refills: same day if possible. Many practices use workflow rules: auto-approve refills if medication is unchanged and patient hasn't had recent dose adjustment. Manual review required for new medications or medication changes.
Can I approve refills automatically?
Yes, if your EHR supports automated approvals. Set rules like: "Approve routine refills for chronic disease medications if refilled within 30 days of last fill and no recent changes." New medications or early refill requests need provider review.
What if a patient asks for early refill?
Check if refill is too early per insurance (copay management). Contact patient: "Your prescription isn't ready for refill yet per insurance. Your next refill date is [date]. Call if you're running out." Some insurance allows early refills for travel or natural disasters.
Should I allow refills for new medications?
No - new medications should be reviewed by provider first. Forms can include dropdown: "Is this a refill or a new medication request?" Route new medication requests to provider for review vs. auto-approving existing medications.
How do I integrate with my pharmacy?
Most EHR systems send electronic refill authorizations (NCPDP standards) to pharmacies. Formbot Pro users can send refill requests via webhook to your EHR or pharmacy system. Alternatively, manually forward approved requests to patient's pharmacy.
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