Prescription Refill

To refill existing prescriptions you must fillout the form completely:

Complete this form (required information is marked with *)
Confirm Identity Information (REQUIRED)
Confirm Contact information (REQUIRED)
Confirm all prescription information
Submit form

For Questions Please Call: Levelland 806-894-7842 Lamesa 806-872-3069 Big Spring 432-517-4557

Last Name: *

First Name: *

City *

State *

Zip Code *

Date of Birth (mm/dd/yyyy) *

Phone # (Include area code) *

Upload Insurance Card (if you are able, if not please fill out the information below for your insurance. If you have no insurance you will be offered a cash price.)

Patient BIN #

Patient PCN #

Patient Group #

Patient ID #

Please select how you would like to receive your prescription(s)... *

	Pickup at Levelland	Pickup at Lamesa	Have shipped to your address
you must have at least one item	Pickup at Levelland	Pickup at Lamesa	Have shipped to your address

Payment options: *

you must have at least one item

Prescription #, Drug Name & Strength (click the +sign to add another prescription) *

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