Rx authorization fax (human)

This is the form a prescriber’s office uses to authorise or renew a prescription for a human patient when we have asked for one — usually because the refills have run out, or because a patient asked us to chase a renewal on their behalf.

Fax it to

832-886-4298

Please send it from the prescribing office rather than from the patient, so the authorisation comes from a verifiable source.

Downloadable form

Editor: attach the PDF here.

Upload your authorisation fax form to the Media Library and link it from this section. This document carries your pharmacy name, address, fax number and licence details, so it should be the version your pharmacist already sends out.

What the form should carry

• Patient name and date of birth.
• The medication requested, with strength, dosage form and quantity.
• Directions for use, and the number of refills authorised.
• Prescriber name, NPI and DEA number where applicable.
• Prescriber signature and the date.

If you are a patient

You do not need this form. Call 832-886-4296 and ask us to request a renewal — we will send the request to your prescriber’s office ourselves and tell you when it comes back.

Response times

We act on an authorisation the day it arrives. What we cannot control is how quickly an office returns one; if a renewal is holding up a medication you are already taking, tell us and we will chase it.