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WEB Current Patient Refill or Prior Authorization Issue

Name, Contact Information and Name(s) of Medications

About Online Forms
The completed form will be emailed to a clinician at Gateway.  As with all electronic communications, email is inherently insecure.  If you want to guarantee the security of your message, please install a secure email service, like Virtru, and email our clinical director at
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This question requires a valid email address.
Controlled Substance Refills Require Discussion
A new California law (implemented in 2017) requires that physicians writing a new prescription or refill for a controlled substance must check a database of prescriptions each time, verify that there are no issues identified, and discuss any issues with patients prior to writing a prescription. This means that we are not able to write prescriptions or refill prescriptions for controlled substances without a conversation with you.. See this post for details. 

The best way to get a medication refill is to contact your pharmacy. Use this form for requests that require special attention, or to make sure that your refill gets filled. 

  • Even if you don't have any more refills authorized, you can contact your pharmacy. The pharmacy will send us an electronic message requesting approval. 
  • If you fill out this form, please include the name, street address and phone number of your pharmacy, so that we can be sure to send the refill to the right place.
  • If you are contacting us about a prior authorization or other insurance issue we may ask you to help by filling in the information about your insurance in a separate PDF that we will email to you after you fill out this form.
  • You can select up to two more medicines later.
  • Choose "other" if the medicine you are concerned about isn't on the list.
What is the dose of each pill. For example, you might be taking "Prozac 1 x 20 mg a day" and for this question you would enter "20." This question requires a valid number format.
For example - "I take two pills in the morning and two pills at night"