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REFILL REQUEST FORM

Note: this remains the preferred refill request method even after the portal transfer to SimplePractice

OVERVIEW of THE REFILL REQUEST PROCESS

(the shortage has caused complications)

1. Call pharmacy to confirm medication is in stock.

2. Submit this refill request and notify Dr. McCarthy (703-288-3535).

3. Keep checking with pharmacy after 2-3 business days to confirm:

     a) The Rx was received (sometimes lost in pharmacy backlog)

     b) The Rx has been filled and is not in "backorder limbo."

4. Give Dr. McCarthy voicemail updates (703-288-3535).

NOTE: Only requests that follow
the                        will be considered.

Patient

Who is completing this form?

 All fields Required

*

3 Business Days for Refill Requests

The medication "shortage" requires additional processing time (e.g., for repeated prescription resubmissions).

Medication

Days Supply

(If authorized by treatment plan and insurance)

Pharmacy

Reserved for specific prescription details. It is not for clinical questions or any non-prescription matters.
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For 90-day requests, please confirm that this was discussed at your last visit and that you have confirmed authorization by your insurance.

Message

Required Acknowledgements

*

I understand and agree that:

*

I have scheduled an appointment in compliance with the 3-month policy

NOTE: In compliance with federal regulations, and to minimize prescription delays, the next available appointment may be scheduled as a “parent-only” visit in the office or by telemedicine, especially if a child patient is unavailable.

*

My next appointment:

12:00 AM

Success!

Your request has been submitted

CATHERINE MCCARTHY, MD • 6723 WHITTIER AVENUE, SUITE  403 • MCLEAN,  VA 22101 • 703•288•3535

© 2024 by CATHERINE MCCARTHY, MD

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