Healthcare DEA Letter

HEALTHCARE DEA LETTER — PATIENT AUTHORIZATION & PRESCRIBER VERIFICATION

1. Purpose

This document verifies the prescribing practitioner's authority to prescribe controlled substances and constitutes the patient's informed authorization for release and verification of controlled substance prescription records as necessary for safe treatment, regulatory compliance, and lawful investigation. The patient authorizes the disclosure described below and acknowledges the risks and responsibilities associated with controlled substance therapy.

2. Patient Information

Patient Name:    Date of Birth:

3. Insurance & Pharmacy

4. Prescriber / DEA Registration

Prescriber Name:    Practice:

5. Controlled Substance Treatment Details

6. Authorization to Release and Verify Controlled Substance Records

I authorize the prescriber named above, my pharmacy, and my health care providers to release and verify my prescription records and related medical information regarding controlled substances to:

- Lawful regulatory or investigatory entities, including the Drug Enforcement Administration and its authorized agents, for the purpose of prescription verification, regulatory compliance, investigation of potential diversion, or disciplinary processes;

- Other health care providers involved in my care for purposes of clinical coordination and safe prescribing.

Unless an earlier date is indicated above, this authorization will automatically expire one year from the date of signature below. I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

7. Patient Acknowledgments and Consents

By checking each box I acknowledge and consent to the corresponding statement. My initials or check constitute a material part of this authorization.

  I have been informed of the risks and benefits of controlled substance therapy, alternatives, and I accept the risks associated with therapy.

  I will use these medications only as prescribed by the named prescriber and for the diagnosed condition.

  I acknowledge that sharing, selling, or diverting controlled substances is illegal and may result in criminal or civil penalties and discontinuation of therapy.

  I consent to periodic monitoring, which may include prescription monitoring database checks, pill counts, and urine or other drug testing as part of ongoing treatment.

  I understand I may revoke this authorization in writing except to the extent that actions have already been taken in reliance on it.

  I understand that refusal to participate in agreed monitoring or diversion concerns may result in cessation of controlled substance prescribing.

8. Medical History (Relevant)

9. Legal & Privacy Notices

Records released pursuant to this authorization may include protected health information related to controlled substance prescriptions. Information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy law. The provider will take reasonable steps to limit disclosures to information necessary for the stated purposes.

This authorization is voluntary. Treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except where permitted by law. The prescriber certifies that the DEA registration information provided in this form is accurate to the best of the prescriber's knowledge and that prescriptions will be written for legitimate medical purposes in the usual course of professional practice.

10. Acknowledgement of Verification

By signing below I acknowledge that I have received explanation regarding prescriber licensure and DEA registration, that I have had the opportunity to ask questions, and that I consent to the release and verification of controlled substance prescription records as described.

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