Healthcare C2 RXs Form

Healthcare C2 RXs Form

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Prescription Request (Controlled Substance — Schedule II)

Medication Name:

Strength / Form:    Dose / Frequency:

Quantity Prescribed:    Days' Supply (estimated):

Transmission Method: Electronic Prescribing Paper Rx to pharmacy Telephone authorization

Acknowledgments, Risks and Patient Responsibilities

I acknowledge that this request concerns a Schedule II controlled substance. Schedule II medications may cause physical dependence, addiction, respiratory depression, and other serious adverse effects. I agree to follow the prescriber's directions and understand that deviation from the prescribed dose or frequency can be dangerous.

I understand that Schedule II prescriptions generally may not be refilled. I will not request early refills or replacement prescriptions for lost or stolen medication without notifying the prescriber. Partial dispensing laws and clinical judgement may apply; I consent to partial fills if clinically indicated and permitted by law.

I agree to safeguard medications securely, not to share them with others, and to dispose of unused medication according to safe-disposal guidance. I understand that the prescriber may require periodic in-person evaluations, urine drug screening, pill counts, or consultations with other treating clinicians as a condition of ongoing therapy.

Privacy and Information Release

By signing below I authorize the practice and prescribing clinician to disclose medical information related to this prescription to dispensing pharmacists, other treating clinicians, and healthcare entities as necessary to support safe prescribing, dispensing, and care coordination. I consent to transmission of my prescription and related information by secure electronic means where permitted.

I understand that my prescription information may be subject to state and federal controlled substance reporting requirements and may be accessed by authorized agencies for monitoring and enforcement purposes.

Authorization and Expiration

If a guardian or authorized representative signs on behalf of the patient, the relationship must be provided and supporting documentation may be required. The patient or authorized representative may withdraw this authorization in writing at any time, except to the extent that action has already been taken based on this authorization.

Prescriber Information (for office use)

DEA Number:    NPI Number:

Patient Certification and Signature

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have read and understand the risks and responsibilities associated with Schedule II medication therapy as stated above. I consent to treatment and to release of information as necessary to facilitate safe prescribing and dispensing.

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