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Edit Content
About Us
Meet Our Founder
Meet Our Team
Accepted Insurance
Blog
Our News
Contact Us
Patient Portal
Patient Reviews
Conditions
Addiction & Substance Abuse
ADHD
Alcohol Addiction
Bipolar Disorder
Delusional Disorder
Dementia with Behavioral Disturbances
Depression
Eating Disorder
Mood Disorders
OCD
Panic Disorder
Personality Disorder
Phobias Disorder
PTSD
Schizoaffective Disorder
Schizophrenia
Sleep Disorders
Somatization Disorders
Stress & Anxiety
Tardive Dyskinesia
Treatments
Buprenorphine Treatment
Dialectical Behavioral Therapy
Family Psychotherapy
Group Therapy
Individual Therapy
IOP Intensive Outpatient Program
Ketamine Infusion Therapy
Long Acting Injectables
Panic Disorder Treatments
Psychiatric Medication Management
SPRAVATO™ (Esketamine)
Substance Abuse Psychotherapy
Supportive Psychotherapy
Therapy
TelePsychiatry
Transcranial Magnetic Stimulation (TMS) Therapy
Vivitrol Injections
Mental Health Tests
ADHD / Conner’s Testing
eVox (Cognitive Test For Dementia)
GAD7
Personality Assessment Inventory Testing (PAI)
Pharmacogenomic Testing
Psychiatric Evaluation
Psychological Assessment
PHQ9 – Questioner
Rapid Mood Screener
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Contact Us
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Patient Reviews
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Medical Records Release Request
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About Us
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Meet Our Team
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Contact us
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Conditions
Addiction & Substance Abuse
ADHD
Alcohol Addiction
Bipolar Disorder
Delusional Disorder
Dementia with Behavioral Disturbances
Depression
Eating Disorder
Mood Disorders
OCD
Panic Disorder
Personality Disorders
Phobias Disorder
PTSD
Schizoaffective Disorder
Schizophrenia
Sleep Disorder
Somatization Disorders
Stress & Anxiety
Tardive Dyskinesia
Treatments
Buprenorphine Treatment / Suboxone
Dialectical Behavioral Therapy
Family Psychotherapy
Group Therapy
Individual Therapy
Intensive Outpatient Program (IOP)
Ketamine
Long-acting Injections
Panic Disorder Treatment
Psychiatric Medication Management
SPRAVATO™ (Esketamine)
Substance Abuse Psychotherapy
Supportive Psychotherapy
Therapy
TelePsychiatry
Transactional Magnetic Stimulation (TMS)
Vivitrol Injections
Tests
ADHD / Conner's Testing
eVox (Cognitive Test For Dementia)
GAD7
Personality Assessment Inventory Testing (PAI)
Pharmacogenomic Testing
PHQ9 - Questioner
Psychological Assessment
Psychiatric Evaluation
Rapid Mood Screener
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Refill Request
It is imperative that you schedule an appointment with us prior to requesting a refill.
Would you like to schedule an appointment now?
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Date
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Date Submitted
Certain Refill Requests may not be processed without an appointment with the Provider.
For controlled medications, it is a requirement for patients to schedule an appointment with Mid Cities Psychiatry before a refill can be issued.
For non-controlled medications, if it has been three months or more since your last appointment, it is a requirement for patients to schedule an appointment with Mid Cities Psychiatry before a refill can be issued.
For non-controlled medications, refills will only be prescribed until the patient’s next appointment. The patient needs to make sure to have an appointment with the provider when submitting a refill request.
The provider retains the right to deny the Refill Request pending toxicology results and they have the right to request an appointment with a patient before processing a Refill Request.
Please allow at least 5 Business Days to process refill requests. There’s a $25.00 charge to process a refill request in less than 5 Business Days.
Refill Requests will be processed for:
Patients that complete the following Refill Request Form
Pharmacies that submit an electronic Refill Request or Fax at #855-295-2686 on behalf of a patient
For questions and/or concerns about the Refill Requests, please feel free to directly send a secured message to the provider’s Medical Assistant by clicking the Patient Portal below.
I Agree
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I Agree
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Is your medication refill request specifically for controlled substances?
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Yes
No
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Please confirm the date of your most recent Meds Management appointment at Mid Cities Psychiatry?
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Patient's Last Name
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Date of Birth
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Date of Birth copy
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Age
*
We apologize for the inconvenience, we only see patients 16 years of age or older.
Do You Have A New Phone #?
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New Phone #
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Same Phone #
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New Email
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Address
Have you moved?
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Street Address
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Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Upload back image of your Driver's License
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Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
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Do you have new insurance?
*
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No
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New Insurance
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Select Insurance
Aetna
Allsaver
American Behavioral Health
Blue Cross Blue Shield
Care Improvement Plan
Care N Care
Cigna
CompSych
GHI - BMP
Golden Rule
Group and Pension Administrator(GPA)
HealthScope
HealthSmart (Network)
Humana
Magellan Behavioral Health
Medicare
Molina Texas Healthcare
Mulitiplan (Network)
Mutual of Omaha Medicare Advantage Plan
New Era Life Insurance
PHCS (Network)
Scott & White Health Plan
Silver Back TPA
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UMR
United HealthCare
Other Insurance
Other Insurance
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Upload front image of your Insurance Card
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Upload back image of your Insurance Card
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Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
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Do you have new secondary insurance?
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No
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New Secondary Insurance
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Select Insurance
Aetna
Allsaver
American Behavioral Health
Blue Cross Blue Shield
Care Improvement Plan
Care N Care
Cigna
CompSych
GHI - BMP
Golden Rule
Group and Pension Administrator(GPA)
HealthScope
HealthSmart (Network)
Humana
Magellan Behavioral Health
Medicare
Molina Texas Healthcare
Mulitiplan (Network)
Mutual of Omaha Medicare Advantage Plan
New Era Life Insurance
PHCS (Network)
Scott & White Health Plan
Silver Back TPA
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Tricare For Life
Triwest
UMR
United HealthCare
New Secondary Insurance ID #
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Secondary Insurance Group #
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Provider's Name
*
Choose Your Provider
Ashley Ibbotson, PhD
Bailey Hofer, MSC, PA-C
Brenda Broadnax, MS, LPC
Debora Simpson, MA, LPC
Haylee Hughes, MPAS, PA-C
Heather Spengler, MSC.PMHNP-BC
Jackquelyn D. Williams, DNP, APRN, FNP-C, PMHNP-BC
Jasmine Webbs, MSW, LCSW
Jenny Bui, MMS, PA-C
Nancy Sperry, MS, MA, LCSW
Philip Lafontaine, MPAS, PA-C
Dr. Ramya Seeni, MD
Rebecca Perthel, MMSC, PA-C
Dr. Seema Kazi, MD
Susana Cardenas, MSW, LCSW
Triet M. La, DO, MS
Wing Kei Chiu, MPAS, PA-C
Medication to Refill
*
Dosages
(for different medications to be filled by different pharmacies, please complete additional Refill Request Form for each pharmacy)
Pharmacy Name
*
Street Address
*
City
*
State
*
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State
Zip/Postal Code
*
Pharmacy Phone #
*
Do you have an Additional Refill Request?
*
Yes
No
Medication to Refill
*
Dosages
Preferred Pharmacy
*
Select Preferred Pharmacy
New Preferred Pharmacy
Pharmacy Name
*
Street Address
*
City
*
State
*
Select Your State
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Alaska
American Samoa
Arizona
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California
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Florida
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Montana
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New York
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North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
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Rhode Island
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Armed Forces Europe
Armed Forces Pacific
State
Zip/Postal Code
*
Pharmacy Phone #
*
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Do you have an Additional Refill Request?
*
Yes
No
Medication to Refill
*
Dosages
Preferred Pharmacy
*
Select Preferred Pharmacy
New Preferred Pharmacy
New Preferred Pharmacy 3
Pharmacy Name
*
Street Address
*
City
*
State
*
Select Your State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
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Wisconsin
Wyoming
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State
Zip/Postal Code
*
Pharmacy Phone #
*
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Please call us at 817-488-8998 Ext. 3 if your medication is not filled within 4-5 business days.
Please Note; processing your form may take 1-2 minutes. To avoid delays, kindly press the submit button Only Once and wait for the thank you message.
We appreciate your patience.
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Please select your Prescriber
*
Choose Your Provider
Annalee Alston, PA
Bailey Hofer MPAS, PA-C
Haylee Hughes, PA-C
Jenny Bui, PA-C
Patricia Nkhono
Rebecca Perthel, MMSc, PA-C
Dr. Seema Kazi, MD
Wing-Kei "Kaye" Chiu, PA-C
Contact Us!
1323 E Franklin Street, #102 Hillsboro, TX 76645
(254) 266-6262
(855) 295-2686
Monday – Friday, 8 am-5 pm
200 Westpark Way, Euless, TX 76040
(817) 488-8998
(855) 295-2686
Monday – Friday, 8 am-5 pm
