Forms and Prescription Refill Request
Please Note:
Policy: We require 72 hours advance notice to call in prescriptions with no refills remaining and for writing scripts for controlled substances. If you have refills, please contact your pharmacy to request a refill.
To request a refill for your prescription please complete the form, or call (319) 626-3300 and select Option 1.
We will make every effort to accommodate emergencies.
Please note: If you have missed appointments or not been seen as recommended by your clinician, we may ask you to schedule an appointment at the time of refilling your prescription in order to provide safe and effective care, and to be in compliance with Federal and State prescribing guidelines.
Printable Forms
-
Click here to open and download the full packet of information.
-
Below are the individual pages that can be found in the New Patient Information Complete Packet.
-
Click Here to open and download the HIPPA Notification of Privacy Practices.
Click Here to open and download the HIPPA Receipt Confirmation Form
-
Click Here to open and download the Authorization to Request Protected Information.
-
Click Here to open and download the Authorization to Release Protected Information.
-
Click Here to open and download the Authorization to Release Protected Information.
-
Click Here to open and download the School Report Form.