Prescription Medicine Refill Request

Patient Information:

Prescription Details:

Additional Information:

Consent and Authorization:

Authorization for Release of Medical Information

I hereby authorize Psychiatric Specialists of Texas to release my medical information to the following individual/organization:

Recipient's Name/Organization: Address: City, State, ZIP Code: Phone Number:

I understand that the information to be released may include, but is not limited to, the following:

• Medical history
• Diagnosis
• Treatment plans
• Medication records
• Laboratory results
• Radiology reports
• Progress notes
• Discharge summaries

I authorize the release of the above information for the purpose of refilling the patient's prescription medication.

I understand that I have the right to revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. The revocation must be in writing and submitted to Psychiatric Specialists of Texas.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.

Consent to Refill Prescription

I hereby authorize Psychiatric Specialists of Texas to refill my prescription medication as specified below. I understand that this authorization is voluntary and that I have the right to revoke it at any time.

I confirm that the information provided is accurate to the best of my knowledge. I understand that it is my responsibility to inform Psychiatric Specialists of Texas of any changes to my prescription or medical condition.

I understand that by consenting to this refill request, I am authorizing Psychiatric Specialists of Texas to release my prescription information to the designated pharmacy for fulfillment purposes.

I acknowledge that Psychiatric Specialists of Texas will not be liable for any errors resulting from inaccurate or incomplete information provided by me.