Refill Request at Three Rivers Mental Health

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Please allow at least 72 business hours for requests on all current medications. This does not include weekends and MA legal holidays when the office is closed.

Email *

Patient First Name *

Patient Last Name *

Patient Phone Number *

Who is your current presciber? *

Pharmacy *

Please specify pharmacy NAME and ADDRESS including ZIP CODE

Medication Refill Request
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Does your insurance require a 90 day supply of your medication or do you typically receive a 90 day supply of your medication?
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Is there any other information you'd like to add about your request?

If you are requesting a stimulant and your last appointment was 3 months ago or more your refill will automatically be denied. You MUST have a visit first to receive a refill.

We will make every effort to fill your medications as soon as possible. We will not confirm sending in your medication due to the number of requests. We will only contact you if your request is denied. PLEASE CHECK WITH YOUR PHARMACY TO SEE IF YOUR PRESCRIPTION HAS BEEN FILLED or if they have one "ON HOLD" for you in the computer. Reasons for denial may be due to lack of recent appointment or lack of scheduled appointment or because the prescription is too early to be filled or has been previously discontinued.

Do you have an upcoming appointment scheduled with your provider?
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If you do not have an an appointment scheduled and need to make one, please contact our office at (857) 229-2852 via phone or text.

Did you just request an appointment?
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If a patient has not been seen at the interval requested by their provider during their last meeting, the provider may deny the request for a refill. Requesting an appointment if you do not have one may reduce the chance that your refill request will be denied. If your request has been denied we will notify you of this and the reason for the denial. If you are current on all appointments you may not be required to request an appointment. Patients who repeatedly request medications and then cancel or no-shows to appointments may be denied refills due to lack of proper follow up.

By checking this box, I show that I understand that repeatedly not making or canceling appointments and then requesting refills may result in that refill request being denied until the person can be seen and/or discharge from the practice due to the clinician's inability to monitor for the patient's safety according to standards of care set forth by the American Psychiatric Association. In such a case patient's will be encouraged to go to the ER or Urgent care for their prescriptions. Please note this does not apply to patients who attend their appointments regularly and simply are having difficulties with the pharmacy, similar reasons beyond their control, or for patients who very infrequently miss or cancel appointments.

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