Healthcare Pharmaceuticals Form

HEALTHCARE PHARMACEUTICALS FORM

This Healthcare Pharmaceuticals Form documents patient identification, insurance, clinical information, and patient authorization for administration or dispensing of prescription pharmaceuticals. Completion of this form constitutes the patient’s informed consent for the medication(s) listed below and authorization to disclose necessary protected health information to a pharmacy or other health care provider for treatment and billing purposes.

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy/Member ID:    Group #:

Subscriber DOB:    Insurance Phone:

Medical History

Medication Request / Order

Strength:    Dosage Form:

Route:    Dose:    Frequency:

Start Date:    End Date:

Quantity:    Refills:

Prescribing Provider (for record)

Administration & Dispensing Instructions

Intended disposition: Dispense to patient Administer in clinic Sample provided

Acknowledgements and Consent

I acknowledge that I have been informed of the medication name, intended benefits, common and serious risks, and alternatives, and I have had an opportunity to ask questions. I understand that all medications carry the risk of side effects and that I should report unexpected symptoms to a health care professional promptly.

I certify that the medication and allergy information I have provided is complete and accurate to the best of my knowledge: I certify

If this medication is a controlled substance, I understand appropriate state and federal regulations apply, including recordkeeping and possible limits on refills.

HIPAA Authorization & Release

I authorize the release of my protected health information related to the medication(s) in this form to the pharmacy named above and to my health care providers for the purpose of treatment, coordination of care, and billing. This authorization permits disclosure of medication name, dosing, diagnosis, insurance information, and allergy history as necessary.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. This authorization does not affect any records created or released prior to receipt of revocation.

Authorization expiration date (if left blank, authorization expires one year from signature):

Patient Certification

By signing below I certify that I have read and understand the information on this form, that the information I provided is true and complete, and that I consent to the administration or dispensing of the medication(s) as ordered. I understand that I may withdraw consent by written notice as described above.

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