Healthcare Pharmaceutical Document

HEALTHCARE PHARMACEUTICAL AUTHORIZATION AND CONSENT

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other Decline to State

Insurance and Billing

Medication Order / Services Requested

Prescribing Clinician:    Provider Phone:

Name:    Dose:    Frequency:

Quantity:    Refills:    Special Instructions:

Name:    Dose:    Frequency:

Medical History

Authorization, Consent and Release

I hereby authorize the pharmacy, its agents and employees to provide pharmaceutical services as directed by the prescribing clinician identified above. I authorize the pharmacy to obtain, use, and disclose protected health information (PHI) as reasonably necessary for dispensing, billing, care coordination, prior authorization, and quality assurance. This authorization includes release of information to my health insurer, prescribing clinician, and applicable care team members.

I authorize the pharmacy to submit claims and receive payment directly from my insurer on my behalf and to apply any payments to amounts due for medications and services rendered. I understand I remain responsible for any co-payments, deductibles, or amounts not covered by insurance.

I acknowledge that I have been informed of common risks and adverse effects associated with prescribed medications and that no guarantee has been made regarding results. I consent to counseling by pharmacist or clinician and understand I may refuse or discontinue a medication at any time. I further acknowledge that controlled substances are subject to additional regulation; I will not share or divert controlled medications and I understand unlawful distribution may be prosecuted.

This authorization is valid until: unless earlier revoked in writing. Revocation does not affect actions taken in reliance on this authorization prior to receipt of the revocation.

If I have provided insurance information above, I authorize my insurer to release payment and information necessary to adjudicate claims. I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that falsification may result in denial of services.

Acknowledgment of Privacy Practices

I acknowledge receipt of the pharmacy's Notice of Privacy Practices and understand how my health information may be used and disclosed in accordance with that notice. I understand my rights to request restrictions, receive confidential communications, and inspect my health records, subject to applicable law.

Additional Authorizations and Notices

I authorize the pharmacy to contact me by telephone, text message, or electronic mail regarding my prescriptions, refill reminders, prior authorization status, or other matters related to my medications. I understand that unencrypted communications may be used and that confidentiality cannot be absolutely guaranteed.

Patient Certifications

By signing below I certify under penalty of perjury that I am the patient named on this form or am authorized to act on behalf of the patient. I certify that all information provided is complete and accurate. I authorize the actions described above and accept financial responsibility as indicated.

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