TX BHC Refill Request Form 2016-2026 free printable template

9525 Katy Freeway, Suite 312 Houston, TX 77024 Tel: (713) 4639449 Fax: (713) 4637181Refill Request Form Date: / / Patient Name: DOB: Patient Tel: Address: Pharmacy: Pharmacy Tel: Pharmacy Fax: Medication

How to fill out TX BHC Refill Request Form

How to fill out TX BHC Refill Request Form

1. Obtain the TX BHC Refill Request Form from your healthcare provider or pharmacy.
2. Fill in your personal information, including your name, date of birth, and contact information.
3. Provide details about the medication you are requesting to refill, including the name and dosage.
4. Indicate the prescription number and the date of your last fill.
5. Sign and date the form to authorize the refill request.
6. Submit the completed form to your pharmacy or healthcare provider either in person, via fax, or through their online system.

Who needs TX BHC Refill Request Form?

1. Patients who are currently prescribed medications that need refilling.
2. Individuals who manage chronic conditions that require continuous medication.
3. Those who are receiving care from the Texas Behavioral Health Center (BHC) and need an official refill request.

People Also Ask about

How do I submit prior authorization to Express Scripts?

Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.

Why does Express Scripts require prior authorization?

Prior authorization ensures that you get the prescription drug that is right for you and that is covered by your benefit. If it's determined that your plan doesn't cover the drug you were prescribed, you can ask your doctor about getting another prescription that is covered. You'll receive it for your plan's copayment.

How do I use my Express Scripts prescription card?

Please show your Express Scripts member ID card to your pharmacist when filling a prescription for yourself or a covered family member. You will also be able to access your member ID card anytime from your Smartphone if you download the Express Scripts Mobile App.

What is my member ID for Express Scripts?

Depending on your plan, you received either a prescription benefit ID card or a combined ID card for both your medical and prescription benefits. You can find your member ID number on this card.

How do I use GoodRx with Express Scripts?

GoodRx compensates Express Scripts. When GoodRx is offered within the pharmacy benefit, its will make a payment back to Express Scripts (PBM #2 above) whenever the patient's out-of-pocket cost with the discount card is lower than their out-of-pocket cost via the Express Script-managed benefit plan.

How do I fax a prescription to Express Scripts?

Your provider can also fax your prescription to Express Scripts® Pharmacy — they can call (888) 327-9791 for faxing instructions. Be sure to give them your member ID number. (Only providers can fax prescriptions.)

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What is TX BHC Refill Request Form?

The TX BHC Refill Request Form is a document used to request a refill of certain medications issued by the Texas Behavioral Health Center (BHC).

Who is required to file TX BHC Refill Request Form?

Patients who have been prescribed medications that require refill authorization from a Texas Behavioral Health Center are required to file the TX BHC Refill Request Form.

How to fill out TX BHC Refill Request Form?

To fill out the TX BHC Refill Request Form, complete all relevant sections including patient information, medication details, and the prescribing physician's information. Ensure to provide accurate and current contact information.

What is the purpose of TX BHC Refill Request Form?

The purpose of the TX BHC Refill Request Form is to facilitate the refill process for prescribed medications and ensure compliance with regulatory standards in medication management.

What information must be reported on TX BHC Refill Request Form?

The information that must be reported on the TX BHC Refill Request Form includes the patient's name, date of birth, medication name, dosage, prescribing physician's name, and the reason for the refill request.