HIGHTSTOWN MEDICAL ASSOCIATES
Refill Request Form
Please note the following items before proceeding:
- This form is NOT HIPAA compliant! It is not encrypted and could be intercepted and read by others. For secure submission of HIPAA compliant encrypted, password protected forms, please use the Patient Portal and submit your request there.
- Please contact your pharmacy first to see if there are already refills authorized on your prescription.
- If you are not a patient of Hightstown Medical Associates, please do not waste your time or ours filling out this form - it will be ignored.
- In the form below, please fill in all relevant fields. SUBMIT the form when complete. Forms submitted without the required identifying information will be ignored. Please include the prescription ID number, if available.