I hereby authorize BEVERLY GLEN PHARMACY to automatically refill prescriptions listed on this form. It is my responsibility to notify the Pharmacy of any changes in mailing address, drug dose, or refill schedule to prevent any unnecessary fills. It is my responsibility to contact the Pharmacy in WRITING by filling out the AUTO REFILL DISCONTUANCE form if I wish to discontinue a single or multiple medications. If you wish to discontinue automatic refills entirely, please email the pharmacy at optout@beverlyglenrx.com or by filling out the AUTO REFILL DISCONTINUANCE FORM and selecting ALL MEDICATIONS. Prescriptions may not be returned once they have left the pharmacy. If you request a discontinuance, you will be entitled to a refund. Automatic refill enrollment will expire 1 year after enrollment, and ongoing consent will be required for continued participation. All SCHEDULED II MEDICATIONS (i.e. ADDERALL, RITALIN, CONCERTA, VYVANSE), GLP-1 MEDICATIONS (i.e. OZEMPIC, MOUNJARO, ZEPBOUND), INSULIN PRODUCTS, EYE DROPS, and AS NEEDED (PRN) drugs will be EXCLUDED from participation.
Auto refills are generated 5 days before your prescription is intended to run out. This is designed to reduce waste and increase compliance. No medications will be automatically shipped so please contact the pharmacy to arrange delivery. You may contact the pharmacy via phone at 310-475-0568, via text at 833-538-1249, or email at info@beverlyglenrx.com
