Healthcare Medication Prescriber Form

HEALTHCARE MEDICATION PRESCRIBER FORM

This form documents the prescriber's medication order, clinical justification, patient clinical information, and the prescriber's attestation. The prescriber certifies that the information provided is accurate and that the medication is prescribed in accordance with applicable professional standards and state and federal law.

Patient Information

Date of Birth:    Gender:

Primary Phone:    Patient ID/Account #:

Insurance Information

Policy Number:    Group Number:

Medical History / Clinical Information

Height:    Weight:

Medication Order

Strength / Dose:    Route:    Frequency:

Quantity to Dispense:    Refills Authorized:    Duration:

Substitution Permitted (Leave blank if no):    Dispense as Written / No Substitution:

Controlled Substance Information

Prescribed as a controlled substance:

If controlled, schedule classification (check all that apply):    Schedule II    Schedule III    Schedule IV    Schedule V

Authorization / Prior Authorization

Prior authorization required:

Privacy Acknowledgment

I acknowledge that the patient has been provided with the Notice of Privacy Practices and that protected health information may be disclosed to fulfill this medication order and any required prior authorization processes.

Patient informed of privacy practices:

Prescriber Information & Certification

Professional Title:    NPI Number:

State License Number:    Office Phone:

By signing below, I certify that I am a licensed prescriber authorized to prescribe medications in the state where this order is issued. I attest that the medication prescribed herein is medically necessary, that the information contained in this form is true and complete to the best of my knowledge, and that I will comply with all applicable laws and regulations concerning prescribing and dispensing.

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