(Please submit completed forms and all documentation to the Chickasaw Nation Pharmacy Refill Center)
1. Application Form for Native & Non-Native Spouse Prescription Program
This form is required for all participants in order to verify eligibility for the Native & Non-Native Spouse Prescription Program. The form must be completed and returned to the Chickasaw Nation Pharmacy Refill Center before a patient can be eligible to receive medications.
2. Notice of Privacy Practices for the Chickasaw Nation Refill Center
3. Acknowledgement of Receipt of Notice of Privacy Practices Form
This acknowledgement form must be signed and returned to the pharmacy before any patient can be eligible to receive medications.
4. Copies of CDIB card, Tribal Citizenship card, Prescription Insurance card, and Marriage License (if applicable).
5. Once your application is approved, submit your prescriptions to the Chickasaw Nation Refill Center for processing. Approved medications are provided at no cost to patients.
6. When it is time to refill your medications, you may use any of the convenient options listed below:
– Web Refill Patient Portal (located on this website)
– RefillPro smartphone application (located on this website)
– Call the pharmacy directly using our toll free number 1-855-472-8725