Healthcare C2 RX Form

HEALTHCARE C2 RX FORM

Purpose: This form documents an order for a Schedule II controlled substance. Prescriber must complete all required fields legibly. Federal and state law prohibit alteration, forging, or unauthorized dispensing of this prescription. No refills are permitted on Schedule II prescriptions except as allowed by law for partial fills; any partial dispensing must be recorded by the dispensing pharmacist.

Patient Information

Patient Name:    Date of Birth:

Gender:    Phone:

Insurance Information

Medical History (Relevant)

Prescription Order (Schedule II)

Medication (drug name):    Strength:

Dosage Form:    Route:

Date Written:    Prescription Valid Until:

Partial fill permitted per applicable law and documented by pharmacist     Do not substitute     Brand medically necessary

Emergency oral administration authorized (if used, prescriber must provide a written prescription within the time required by law)     Follow-up written prescription date:

Prescriber Information & Certification

Certification: By signing below, the prescriber certifies that the controlled substance is being prescribed for a legitimate medical purpose in the usual course of professional practice; that the prescriber has evaluated the patient, verified identity and medical necessity, and will maintain required records. The prescriber acknowledges compliance with all applicable federal and state controlled substance laws and regulations.

Patient Acknowledgment (Initials)

I acknowledge receipt of counseling on the risks, benefits, and alternatives to the prescribed medication and authorize release of prescription information to pharmacies and insurance payers as necessary for dispensing and payment: Patient Initials:    Relationship (if signed by guardian):

Legal Notice / Dispensing Instructions

Warning: It is unlawful to possess or dispense this prescription without the prescriber's authorization. Any person who knowingly forges or alters a prescription may be subject to criminal and civil penalties. The pharmacist must document any partial dispensing and the remaining quantity must be dispensed in accordance with applicable law. Prescriber must not authorize refills for Schedule II substances.

Records Release Authorization: By signing, the prescriber authorizes release of necessary medical information to pharmacists, pharmacies, and payers for the purpose of filling this prescription and for continuity of care; all disclosures shall be consistent with patient privacy obligations.

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