Report Faxed Refill

Before reporting this issue, we recommend you complete our checklist to determine if the refill could have been faxed for a legitimate reason.

Pharmacies that are connected to Surescripts network are able to send prescription refill requests electronically - right to your practice computer. Pharmacies that never send you refill requests electronically are likely not connected.

If you are receiving both electronic and faxed refills from a pharmacy that is connected to the Surescripts network, you can report this issue to your vendor or report it directly to Surescripts using the form below.

If you are reporting a faxed renewal request from Kroger, Rite Aid, Walgreens, or Walmart, you only need to report one incident per chain. The issue will be researched and corrected (if necessary) at the chain headquarter level. For all other pharmacies, you can report incidents at the individual store level. Report each chain separately. You can also report faxed refills to your software vendor via your standard support protocol. Important: not all software systems are certified for mail-order renewal requests. Please report faxed refills from mail-order pharmacies directly to your software vendor.

Prescriber Information

*All fields marked with an asterisk must be completed.

Prescriber DEA Number*Subscriber does not have DEA number*

NPI Number (Required if DEA Number is not provided)

First Name*Last Name*Address*City*State*Select.. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana National Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip*Fax*Phone*Email Address*

Pharmacy Information

*All fields marked with an asterisk must be completed.

Pharmacy Name*Store Number*City*State*Select.. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana National Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip*Phone*Fax*

Information to be reported

*All fields marked with an asterisk must be completed.

Approximate date/time you received fax(es):

Date*

Please enter a valid date

Time*

This field is required.

Approximate number of faxes received*When did you start e-prescribing?*Have you contacted anyone at the pharmacy?*Yes No Please select oneName of the individual you contacted:I have not contacted anyone at the pharmacy

Additional Information

Please use the following box to tell us anything else you think we should be aware of with regards to this pharmacy and/or the faxed refill request:Surescripts may need to contact your vendor for assistance with researching this issue or to obtain additional information such as a copy of the fax(es). By leaving this box checked you are authorizing Surescripts to follow up with your e-prescribing vendor. I accept Please check to confirm

*Important Notice: Protected Healthcare Information (PHI) should never be transmitted via this Web site. PHI is any data which can be used to reasonably identify a patient (as defined within the HIPAA Privacy Rule, the HIPAA Security Rule, or elsewhere within the overall HIPAA regulations), or which specifically contains individually identifiable health information. As one example, do not include the Rx Number as this is considered PHI.