Prescription Refill Requests

This prescription refill service is ONLY for refills without any changes from your child's prior prescription. New prescriptions will require a call to our office and, in most cases, will require a visit to your child's doctor.

This prescription refill service will be checked twice per day (Monday through Friday). Requests received over weekends or holidays will be processed on the next business day. Please allow 72 business hours for your request to be processed. Be sure to complete all information on the form to ensure proper service.

Please call the pharmacy before picking up your prescription to ensure that the request has been filled. If your pharmacy has not received the prescription, please call your doctor's office.

Please be aware that if you leave a prescription refill for a controlled substance (such as Adderall, Focalin, Concerta, or Ritalin) the prescription CANNOT be called in to the pharmacy, but will be written and will be available for pick up after 72 hours. This time period allows the nurse and physician to review your child's chart to insure that all is in order for the refill.

To begin filling out the Refill Request Form, click on the appropriate link below:

Alabaster Patients: Click Here for Prescription Refills
Brook Highland Patients: Click Here for Prescription Refills
Hoover Patients: Click Here for Prescription Refills

Disclaimer:  This Rx Refill Form is to be used for your convenience for Children's of Alabama informational purposes only. The information contained in this message is being stored in a secure database. 

Greenvale Pediatrics List of Forms

ADOLESCENT FORMS

ADHD FORMS

ANNUAL INFORMATION RENEWAL FORM

NEW PATIENT FORM

SPORTS RELATED FORM

Business Office Phone Number: 205-987-4460

Financial Policy Addendum - Effective January 1, 2014
Patients who are covered by a Health Insurance Exchange policy and are then placed into a “PENDED” status for failure to pay the required premium will be treated as SELF PAY patients. As such, patients will be required to pay a $90 deposit for the current visit and 100% of all previous uncovered charges prior to being seen. If this status is resolved between the patient and insurance company a refund will be issued to the patient. If the patient refuses to comply with the Greenvale Financial Policy as stated above, the patient will be dismissed from the practice.

Financial Policy

Our primary interest at Greenvale Pediatrics is in taking care of your child. However, we must enforce our payment/financial policy in order to continue to provide your child the best care possible.

Professional fees are due and payable at the time service is rendered. Responsibility for payment is your direct obligation-not your insurance company's. Your co-payment and payment for non-covered services is expected at the time of service.

Our physicians participate in the following insurance plans:

• Blue Cross Blue Shield of Alabama
• Alabama Medicaid
• United Healthcare
• VIVA Health
• Health Choice of Alabama (Aetna)
• Cigna
• Tricare Standard
• Humana-ChoiceCare
• Coventry-First Health
• Multiplan (PHCS-Beechstreet)

It is the patient/caregiver's responsibility to understand their insurance benefit plan. It is the patient/caregiver's responsibility to know if a written referral or authorization is needed to see specialists, if preauthorization is required prior to a procedure and what services are covered.

If a patient/caregiver has no insurance, they will be seen on a cash basis and the charge will be decided by the physician. In documented cases of financial hardship, certain fees may be waived at the discretion of the physician.

When you arrive at Greenvale Pediatrics, you will sign an agreement to pay for any services rendered that are not covered by your insurance. Because we deal with dozens of different insurances, we do not have the ability to track each individual plan. It is very important to check with your insurance before making a well child appointment. Not all plans cover well child check-ups, annual/sports physicals, immunizations, routine labs, or hearing and vision screenings. If any benefit is not covered, it will be the responsibility of the patient/caregiver to make payment at the time of service.

Not all medically necessary services ordered by our physicians are covered by every insurance plan. If we need to send out lab tests that we do not routinely do in our own lab, we use LabCorp as our referred testing lab. Most major insurances will pay for labs/testing done by LabCorp. Please check with your insurance company to make sure that your insurance accepts LabCorp. If your insurance does not accept LabCorp, please let us know ahead of time as you may be charged by LabCorp for non-covered labs. If radiology services are necessary please be aware that radiology centers may bill for services that are applied to your deductible, or are otherwise uncovered. It is important that all patients/caregivers be familiar with the details of insurance plan coverage. Any service ordered by our physicians and not covered by insurance will be the responsibility of the patient/caregiver.

There is a $5 fee for nonpayment of copays at the time of service.

There is a $25 fee for all returned checks.

A $25 charge will be assessed to your account if appointments are not kept or rescheduled 24 hours in advance of appointment time.

After three unkept/uncancelled appointments, as described above, the physician reserves the right to discharge the patient from the practice.

A $5 processing fee will be charged for all immunization (blue card), physical, sports, and camp form when completed outside of an office visit with the physician. This action is necessary to help offset administrative costs associated with the processing of the form.

You should notify our billing office if you need to make special arrangements. An account overdue for 90 days may be referred to an outside collection agency for collection, so please keep us informed of difficulties when they arise. Once your account has been turned over for collection, we will no longer be able to serve fyour child's medical needs.

Divorced Parents

In cases of divorce and /or separation, the person bringing the child in for services will be obligated to pay for any co-pays or balances that are due. The legal guardian and /or the person bringing the child in for services will be held responsible for paying any balance resulting from that visit. If legal documentation is presented that someone other than the legal guardian is financially responsible, and accurate billing information can be provided, we will attempt to bill that party. Ultimately, in the State of Alabama, both biological parents are responsible for debts incurred by their minor children.

You may use your MasterCard, Visa or Discover to charge current services or any outstanding balance on your account. For your convenience, credit card payments can be made via our website by clicking here.

Financial Assistance

You may be eligible for financial assistance under the terms and conditions the hospital offers to qualified patients. For Children’s Financial Assistance Policy contact 1-844-750-8950 or contact the Business Office at 205-638-2722. You can also visit www.childrensal.org/financial-assistance for additional information.

PLEASE NOTIFY US IMMEDIATELY IF YOUR INSURANCE HAS CHANGED - so that we may make certain your claims are sent to the proper company.

Regarding bills or insurance, please call our billing office direct - 205-987-4460 Monday through Friday between 8:00 a.m. and 4:00 p.m.