Get Texas Child Neurology Medication Refill Request Form 2012-2025

Filling out the Texas Child Neurology Medication Refill Request Form online is a straightforward process designed to assist users in requesting medication refills efficiently. This guide will walk you through each section of the form, ensuring you provide the necessary information accurately.

Follow the steps to complete the medication refill request form.

1. Click ‘Get Form’ button to access and open the Texas Child Neurology Medication Refill Request Form.
2. Fill in the physician's name and the date of the request. This information is essential for processing your refill request.
3. Enter the patient's name and date of birth in the designated fields to identify the individual requiring the medication.
4. Provide the patient's address and phone number. This information is crucial for communication and ensuring the medication can be sent appropriately.
5. List the medication name, ensuring to note if it is an extended-release by indicating XR or ER as applicable.
6. Specify the dosage and directions as instructed. It is important to be as clear and detailed as possible.
7. Select the preferred supply option: 30-day supply, 90-day supply (3-30 day scripts), or mail. Review any important notes about ADD/ADHD medications.
8. Provide credit card information, including card number, expiration date, name on the card, and billing address. Indicate if you want Texas Child Neurology to keep your credit card information on file for future refills.
9. Sign the form to authorize Texas Child Neurology to bill your credit card for the refill fee. Ensure to review your information before submission.
10. Once all sections are completed, save any changes made to the form. You may then download, print, or share the finalized document as needed.

Start filling out your form online today to ensure a smooth medication refill process.