• Image-35
  • Medication Request Form

    IMPORTANT!!!!! If you are requesting a refill from the same pharmacy as before, call your pharmacy and ask them to send OSS the request electronically. Contacting the pharmacy first will be faster because the pharmacy will be able to check its inventory and look up costs for you.
  • Directions:

    This form will take you less than 5 minutes.

    Fill out to request:

    • Same prescription medication refill(s) which you received in the last 3 months from an OSS provider and you want it sent to a new pharmacy.
    • Change to a prescription medication which you received from OSS.


    When you fill out the form, HAVE THIS NEXT TO YOU:

    1) Medication bottle(s). Have them next to you so you can enter the information into this form.

    2) Pharmacy Information. Have the pharmacy information available so you can also enter it - including the name of the pharmacy, the address, and the telephone number.

    Keep in mind:

    1) 2 business days. Give OSS 48 hours to review and send in your prescription to the pharmacy.

    2) More than 3 months? If it's been more than 3 months since you have seen the provider, OSS will require that you book an appointment to discuss the medication request.

    3) 4 weeks. OSS will only prescribe a narcotic for up to 4 weeks after you have an acute injury or surgery. If you ask your provider for more beyond the 4 weeks, you will be referred to our OSS Pain Management Specialist or to your primary care doctor.

    4) Asking for a change to medication because you are having side effects? OSS may contact you within these 2 business days.

    5) The provider will decide how much of the medication you get. This could be the same or different than what you got last time.

    6) Unfortuantely, OSS cannot contact the pharmacy on your behalf to check insurance coverage or if the medication is available or in stock.

  • Should be Empty: