Healthcare PECA EPCS Form

HEALTHCARE PECA EPCS AUTHORIZATION FORM

This form authorizes the electronic prescribing of controlled substances (EPCS) to the named patient in accordance with applicable controlled substance regulation and clinical policy. Patient authorization herein permits the use of electronic prescriptions, identity verification procedures, and electronic transmission and storage of prescription records related to controlled substances for treatment purposes. The patient or authorized representative must complete, sign, and date this form to enable EPCS services.

Patient Information

Emergency Contact

Insurance Information

Medical History & Current Medications

Has the patient ever had a diagnosis of substance use disorder or received treatment for addiction? Yes No If yes, provide details:

EPCS Identity Proofing & Authentication

Identity verification was completed by the following method(s). Select all that apply and provide details where requested.

In-person presentation of government-issued photo ID
Remote identity proofing / knowledge-based verification
Two-factor authentication (one-time passcode to device)
Other (describe below)

EPCS Authorization, Risks, and Acknowledgements

By signing below the patient authorizes the clinical team and authorized prescribers to issue electronic prescriptions for controlled substances. The patient acknowledges that electronic prescribing may involve transmission of prescription data between systems and that safeguards (including authentication and audit logging) will be used to protect prescription integrity.

Patient understands the risks including, but not limited to, potential unauthorized access to electronic records, delays in transmission, or errors in medication selection. Patient also acknowledges the benefits of electronic prescribing, including improved legibility, reduced risk of manual prescription errors, and streamlined pharmacy processing. Patient retains the right to revoke this authorization at any time by submitting written notice to the prescribing clinic; revocation will not affect prescriptions already transmitted in good faith prior to receipt of revocation.

Prescribing clinician or clinic name:

Purpose of authorization (diagnosis / treatment intent):

Authorization expiration date:

I acknowledge that I may withdraw this authorization at any time, except to the extent that action has been taken in reliance on it. Withdrawal must be provided in writing to the prescribing clinician or clinic.

Initial to confirm understanding of EPCS procedures and risks:

HIPAA & Prescription History Release

I authorize the disclosure of my prescription-related health information to other treating providers, pharmacies, and authorized personnel as necessary to facilitate coordinated care and safe prescribing. I understand this release is limited to medication and prescription records relevant to EPCS and clinical care, and that I may revoke this authorization at any time in writing.

I acknowledge receipt of the clinic's Notice of Privacy Practices and understand how my prescription information may be used. Acknowledged

Representative / Guardian

If signing on behalf of the patient, indicate relationship and legal authority.

Yes, I am signing as the patient's authorized representative or guardian

Patient Certifications

By signing below I certify under penalty of law that the information provided on this form is true and correct to the best of my knowledge. I authorize the release of prescription-related information as described above and consent to electronic prescribing of controlled substances by the named clinician(s). I understand that misuse of controlled substances is subject to medical, civil, and criminal penalties.

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