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(301) 840-2208

Medication Refill/Prior Authorization (P.A.) Request Form

Alternatively, you can request a refill by contacting your pharmacy.
Turn-around time:
- Refills: 48 hrs since the date of the request
  (ONLY if the medication is covered)
- Prior Authorization: Unpredictable, usually 14 days or longer
For medications requiring prior authorization (P.A.),
please have the pharmacy initiate the process
For inquiries regarding the status of a refill request,
please contact your pharmacy
For inquiries regarding the status of a prior authorization (P.A.),
please contact your insurance provider

Patients's Full Name

Patients's Date of Birth (mm/dd/yyyy)

Medication’s Name

Medication’s Strength

Number of Refills Requested

Pharmacy’s Name and Location

Pharmacy’s Phone Number (xxx-xxx-xxxx)

Request An Appointment

Maryland Eye Institute

6 Montgomery Village Ave.
Suite 103
Gaithersburg, MD 20879
(301) 840-2208
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Maryland Eye Institute 6 Montgomery Village Ave. Suite 103 Gaithersburg, MD 20879 Phone: (301) 840-2208 Fax: (301) 840-2210