The purpose of this form is to provide you with a comprehensive analysis of your estimated copays and out-of-pocket costs with the current prescriptions you are taking. This form is optional
. If you would like us to review your prescriptions, please provide the information below and return prior
to your appointment by email ([email protected]
), mail (931 N. Last Chance Gulch, Helena, MT 59601), or fax (888-437-6292) so we may better serve you at the time of your appointment. Please call our office at (406) 457-1243 with any questions or concerns. Thank you!
Frequency of prescription refills