Healthcare EPCS Form

Healthcare EPCS Form

Purpose: This form documents the patient's informed consent and authorization to permit electronic prescribing of controlled substances (EPCS) to the patient by the named prescriber and to register devices and authentication methods for that purpose. The patient certifies that the information provided is accurate and understands the risks, benefits, and limits of electronic prescribing.

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History (relevant to controlled substances)

Prescriber / Practice Information

EPCS Authorization and Device Registration

I authorize the above-named prescriber to electronically prescribe controlled substances on my behalf. I understand that prescribing electronically requires registration of devices and use of two-factor authentication. I consent to registration of the devices I indicate below and to transmission of my prescriptions to pharmacies.

CII (e.g., morphine, oxycodone)
CIII–CV (e.g., tramadol, benzodiazepines)
Non-controlled medications via electronic prescription

Mobile phone
Tablet
Desktop / Workstation
Other

I acknowledge that two-factor authentication will be used to authorize electronic prescriptions and that I may be required to use one or more of the following:

Biometric authentication (fingerprint or facial recognition)
Hardware token or key fob
Mobile authenticator app (one-time code)
Secure passphrase / knowledge factor

Delegation and Pharmacy Release

I authorize designated clinical staff or authorized delegates of the prescriber to prepare, transmit, and manage electronic prescriptions on behalf of the prescriber. I also authorize the prescriber and practice to disclose prescription information to pharmacies for the purpose of dispensing medications.

Risks, Benefits, and Right to Revoke

Benefits: Electronic prescribing can reduce errors, speed processing at the pharmacy, and improve continuity of care. Risks: There are risks related to electronic transmission, device compromise, or unauthorized access. I understand that no system is completely secure and that the prescriber and practice maintain administrative, technical, and physical safeguards to protect my information.

Revocation: I may revoke this authorization at any time by delivering written notice to the practice. Revocation will not affect actions already taken in reliance on this authorization prior to receipt of the revocation.

Authorization expiration: This authorization will expire on unless earlier revoked in writing.

HIPAA and Certification

I acknowledge receipt of the practice's notice of privacy practices describing how protected health information may be used and disclosed. By signing below I authorize the use and disclosure of my health information as necessary to effectuate electronic prescribing and to communicate with pharmacies, payors, and delegates as described above.

Certification: I certify under penalty of perjury that I have provided accurate information on this form and that I understand the contents. I authorize the prescriber to register my devices and authentication methods for EPCS and to send electronic prescriptions for controlled substances as permitted above.

Acknowledgments

I request a copy of this signed authorization
I understand the risks and benefits of electronic prescribing
I authorize the practice to contact me regarding device or authentication issues

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