I acknowledge and agree to ClearSpring Pharmacy's Automatic Refill policy as stated below. I am voluntarily requesting to be placed on this program to improve my health and compliance with my medications. I understand my insurance provider may have a mail order benefit but l choose ClearSpring Pharmacy to administer my prescription needs. It is my responsibility to notify Clearspring Pharmacy of any changes in drug dose, or frequency that might affect my medication profile and refill regimen. I acknowledge that should I fail to do any of the above, which may result in an unnecessary fill, it is my financial responsibility. It is my responsibility to notify ClearSpring Pharmacy if I wish to discontinue this service or if my address changes. Notification must be given before the prescription is mailed out from the pharmacy to avoid financial responsibility for the prescription. Prescriptions may not be returned once they have left the pharmacy.