The following form is required if you would like to request your prescriptions be automatically filled and shipped.

Please print this page, sign and fax it to us at 800.458.9182.

Upon receipt, we will set up your refills to be dispensed according to the frequency indicated. Please be sure to read the entire form.

Auto-Refill Authorization Form

BELLEVUE PHARMACY
1034 SOUTH BRENTWOOD BLVD., SUITE 102
ST. LOUIS, MO 63117
PHONE: 800.728.0288 OR 314.727.8787
FAX: 800.458.9182 OR 314.727.2830
EMAIL: INFO@BELLEVUERX.COM
WWW.BELLEVUERX.COM

I, (print name) _______________________________________________ request the following medications be shipped to me automatically per the schedule specified below.

This acknowledgement shall remain in effect until I request that it be terminated by letter or e-mail. I also understand that my prescriptions will be sent by this policy as long as there are authorized refills. If there is need to contact my physician for refill approval, it may delay my shipment. Cancellation of this request will be received via e-mail or fax to confirm termination.

Medication(s)* / Day of month to be filled** / How Often-In Months***

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________
*Indicate name of drug(s) to be filled.
**Indicate the calendar day of the month to be filled.
***How often. Once a month, every two months, etc.

Please list shipping address: ___________________________________________________________________

___________________________________________________________________

Any changes in shipping address or medication order must be sent to the pharmacy seven (7) days before the scheduled fill date. I acknowledge and agree to Bellevue Pharmacy's return policy as stated below.

Signed: ___________________________________________________________

Date: _____________________________________________________________

Email/Phone number to acknowledge receipt of enrollment/termination_______________________________________________

Auto Refill Return Policy

When a patient requests an automatic refill on a scheduled time frame, the medication is also non-returnable. We require a one-week notification of any change in medications, shipping address, or billing information. Once you notify Bellevue Pharmacy of any change, every attempt will be made to stop the preparation and shipping of your medication. If your order has already been shipped from Bellevue Pharmacy, it is non-returnable and no refund will be issued.