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Refill Authorization

Updated: July 1, 2022

ALLERMI MEDICAL ASSOCIATES, P.C.

PATIENT AUTHORIZATION FOR AUTOMATIC REFILLS

Allermi has created a system to automatically refill the prescriptions of your choice when they are available to be refilled. By selecting automatic refills of your prescriptions this gives us the time to contact your provider for more refills, order more inventory to fill your order, and ship your order on time.

If you decide you do not want to participate in our automatic refill program any longer, you can easily opt out at any time by cancelling your Allermi subscription. You will receive notice 72 hours before your order will process and can cancel at any time before your payment is processed.

Once your payment/shipment has processed (meaning it has been billed and sent to the pharmacy for compounding) it cannot be refunded. 

By acknowledging my consent below, I understand and agree to the following:

I consent to my Allermi prescriptions being refilled automatically and agree to the auto refill permissions and return policy of cancelling up to 12 hours after my order has processed.

I acknowledge and agree to the Allermi Automatic Refill policy as stated here. I am voluntarily requesting to be placed on this program to improve my health and compliance with my medications. It is my responsibility to notify Allermi of any changes in address change or information hat might affect my medication profile and refill regimen as soon as possible.

I acknowledge that should I fail to do any of the above, which may result in an unnecessary fill, it is my financial responsibility.

It is illegal to return medication once it has left the union center facility even if it has not been opened.

It is my responsibility to notify Allermi if I wish to discontinue this service or if my address changes.

Notification must be given before the prescription is mailed out from the pharmacy to avoid financial responsibility for the prescription.

Prescriptions may not be returned once they have left the pharmacy.