Tri-City Cardiology

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> Our Locations

Main Phone: (480) 835-6100

Tri-City Cardiology, Dobson
1520 South Dobson Road, Suite 209
Mesa, AZ 85202

Tri-City Cardiology, Baywood
6750 East Baywood, Suite 301
Mesa, AZ 85206

Tri-City Cardiology, Business Office
222 South Power Road, Suite 102
Mesa, AZ 85206

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Prescription Refill

All refill requests for medication prescribed by your Tri-City physicians should be made by your pharmacy. Call your pharmacy if you need a refill, your pharmacist is in the best position to safely and accurately coordinate the request with our staff.

Use this site to notify us that you have initiated a request for prescription refill authorizations or a prior authorization for insurance coverage through your pharmacy.

Read the information on your prescription bottle label. The label contains important refill information such as last fill date, refills remaining and expiration date of the prescription.

Request your prescription refill at least 7 days prior to running out of medication. If you know your prescription has expired or has no more refills, initiate the refill request with your pharmacy at least two weeks before you need it filled.

If your prescription medication needs a prior authorization from your Tri-City physician before it can be refilled, initiate the request through your pharmacy at least 30 days before your need your refill.

If you use a mail order pharmacy, initiate a refill authorization request through your mail order pharmacy. Allow yourself at least 30 days before you run out of medication. Be sure to request a written prescription for a 90-day supply of medication with refills. If you need a supply of medication to hold you over until the mail order medication is available, you may contact us for a prescription that can be filled at a local pharmacy.

Prescription Refill Request:

Patient Name:
Birth date: (ex. 06061999)
Telephone Number:
Your Email:
Tri-City Physician:
Insurance Prescription Card ID Number:
Local Pharmacy Name:
Pharmacy Address:
Pharmacy Telephone Number:

Mail Order Pharmacy Name:
Pharmacy Address:
Pharmacy Telephone Number:

If you use more than one pharmacy, then submit the medication information on this page separately for each store. Take the information off your prescription bottle label for each medication and enter it below. Provide as much information below as you can.

Form 1
RX Number:
Drug and Strength:
Directions:
Quantity:
Original Fill Date:
Date Last Filled:
Expiration or Discard Date:
Refills Remaining:
How many days supply do you have left before you run out of medication?:
Check any specific needs below:
I have notified my pharmacy about my prescription refill needs. I need a prior authorization for my insurance. I need a prescription for a 90-day supply for a mail order pharmacy. I need a prescription for a 30-day supply prior to the mail order delivery. Other, see comments below:
Comments:


Form 2
RX Number:
Drug and Strength:
Directions:
Quantity:
Original Fill Date:
Date Last Filled:
Expiration or Discard Date:
Refills Remaining:
How many days supply do you have left before you run out of medication?:
Check any specific needs below:
I have notified my pharmacy about my prescription refill needs. I need a prior authorization for my insurance. I need a prescription for a 90-day supply for a mail order pharmacy. I need a prescription for a 30-day supply prior to the mail order delivery. Other, see comments below:
Comments:


Form 3
RX Number:
Drug and Strength:
Directions:
Quantity:
Original Fill Date:
Date Last Filled:
Expiration or Discard Date:
Refills Remaining:
How many days supply do you have left before you run out of medication?:
Check any specific needs below:
I have notified my pharmacy about my prescription refill needs. I need a prior authorization for my insurance. I need a prescription for a 90-day supply for a mail order pharmacy. I need a prescription for a 30-day supply prior to the mail order delivery. Other, see comments below:
Comments: