NYS DOCCS Patient Refills

*=required

Contact & Location

Your Name :

*Select NYS DOCCS Correctional Facility Location :

Patient Information

Enter at least one patient's information (up to five patients at a time). Please fill out the entirety of the relevant patient data (file upload and provider name are optional).
File size limit is 4MB. Files larger than that will fail to upload.

*Patient Name :

*Date of Birth :

Provider Name :

*DIN :

Upload a file (up to 4MB) :

*New Rx information, prescription number(s), and/or medication name for refills :

Patient Name :

Date of Birth :

Provider Name :

DIN :

Upload a file (up to 4MB) :

New Rx information, prescription number(s), and/or medication name for refills :

Patient Name :

Date of Birth :

Provider Name :

DIN :

Upload a file (up to 4MB) :

New Rx information, prescription number(s), and/or medication name for refills :

Patient Name :

Date of Birth :

Provider Name :

DIN :

Upload a file (up to 4MB) :

New Rx information, prescription number(s), and/or medication name for refills :

Patient Name :

Date of Birth :

Provider Name :

DIN :

Upload a file (up to 4MB) :

New Rx information, prescription number(s), and/or medication name for refills :

Extra Information

Special Notes :

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