Healthcare Rx Renewal Route

HEALTHCARE RX RENEWAL ROUTE

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medication Requested for Renewal

Strength:    Dosage form:    Quantity requested:

Last fill date:    Current prescriber:

Controlled Substance
Controlled substance (requires additional review; may require in‑person evaluation)

Clinical Information and Justification

Prior Authorization / Administrative

Prior authorization required:

PA submitted date:    PA reference number:

Routing Instructions

Route to (check all applicable):
Primary care provider    Specialist    Clinical pharmacist    RN triage    Provider on-call    Prior authorization team    Other

Urgency: Urgent (within 24 hours)    Routine (48–72 hours)

Authorization to contact pharmacy for refill clarification:

Authorization and Notices

By signing below, I authorize my treating clinicians and designated administrative staff to review my medical record and to communicate with my pharmacy and insurer as necessary to evaluate and process this prescription renewal request. I understand that renewal approval is not guaranteed and the prescriber may require an in‑person evaluation, laboratory monitoring, or additional documentation prior to issuing a renewal. I authorize release of relevant protected health information for the purpose of processing this request.

I acknowledge that electronic transmission of prescription information (including fax or secure electronic messaging) may be used in processing this request. I understand that controlled substance renewals may have additional regulatory requirements and may be denied if criteria are not met.

Authorization expiration date:    I acknowledge and consent to the terms above:

Staff Routing Log (for internal use)

Date routed:    Routed by (initials):    Action taken:

Clinician review completed:    Clinician initials:

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