Online Prescription Refill Form

To refill a prescription, please fill in all fields in the form below. Incomplete forms can not be processed. Requests are normally processed within 2 business days of their submission. Please refer to the Prescription Refill Policy for complete instructions on filling out this form.

Additional Required Prescription Refill Information for Pre-Authorization

  1. For prescriptions requiring pre-authorization, we will need you to fax us the face of your current health insurance card, medicare card and/or medicaid card (as applicable). Please fax to 518-459-7249, Attn. Jennifer.
  2. You will also need to call your health insurance provider and have them fax us the Pre-authorization form. Please fax to 518-459-7249, Attn. Jennifer.

Patient Information    
First Name:
 
Middle Initial:
 
Last Name:
 
Date of Birth (mm/dd/yy):
  
Daytime Phone (include area code):
  ( )
Evening Phone (include area code):
  ( )
Email Address:
 
     
You may enter up to three prescription refill requests on this form. If you require additional prescription refills, please resubmit the form with those requests.
     
Prescription Information
Prescription 1    
Name of Medication:
 
Dosage (in mg):
  
Number of pills you take:
   pill(s) each time I take them
How often a day you take them:
   times per day
Number of months supply you require:
  months supply
Prescription 2    
Name of Medication:
 
Dosage (in mg):
  
Number of pills you take:
   pill(s) each time I take them
How often a day you take them:
   times per day
Number of months supply you require:
  months supply
Prescription 3    
Name of Medication:
 
Dosage (in mg):
  
Number of pills you take:
   pill(s) each time I take them
How often a day you take them:
   times per day
Number of months supply you require:
  months supply
     
Pharmacy Information    
Pharmacy Name:
 
Pharmacy Address:
 
Pharmacy Phone (include area code):
   ( )
     
Comments or questions:
  
   
   

Please note: Emergency-same day-refills requested without an appropriate explanation may be billed a $10 processing fee.

Center for Preventive Medicine & Cardiovascular Health


at Mid-Valley Cardiology
111 Mary's Ave. Suite 3
Kingston, NY
845-339-3663

Main Office
400 Patroon Creek Blvd.
Albany, NY
518-618-1100

at Glens Falls Associates in Cardiology
747 Upper Glen St.
Queensbury, NY
518-793-1083
 
 

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©2003-2004 Paul E. Lemanski, MD, MS. All rights reserved.