Healthcare Pharmacy Addendum

HEALTHCARE PHARMACY ADDENDUM

Patient Information

Date of Birth:

Female Male Other / Prefer not to say

Emergency Contact

Insurance Information

Preferred Pharmacy Details

Phone: Fax:

Medication and Medical History

Pharmacy Authorization and Consents

By signing below, the patient authorizes the treating provider and clinic staff to disclose protected health information (PHI) to the named pharmacy for the purpose of filling, dispensing, coordinating benefits, prior authorization, medication therapy management, and medication-related communications. PHI disclosed may include medication lists, diagnoses, lab results relevant to pharmacotherapy, and prior authorization documentation.

This authorization permits the pharmacy to contact the provider and to receive electronic prescriptions, refill requests, and clarifications. The patient further authorizes the pharmacy to submit claims to the patient’s insurance and to discuss coverage and billing on the patient’s behalf.

Patient acknowledges that electronic transmission of prescriptions and communications may involve standard electronic systems and that the clinic and pharmacy will exercise reasonable safeguards but cannot guarantee absolute confidentiality of transmissions.

The patient specifically authorizes the following actions (check all that apply):

Allow electronic prescribing to the named pharmacy
Allow release of medication history and immunization records to pharmacy
Authorize provider to communicate with pharmacy for prior authorization assistance
Authorize pharmacy to bill patient’s insurance carrier(s) for prescriptions
Permit generic substitution when therapeutically equivalent unless otherwise instructed

Communication Preferences

The patient consents to pharmacy communications regarding prescriptions, refill reminders, and medication counseling via (check preferred methods):

Phone call to listed phone number
SMS/text message to listed phone number
Email to listed email address
Postal mail to listed address

Limitations, Term, and Revocation

This authorization is valid for the purposes stated herein and shall remain in effect until the earliest of: the authorization expiration date specified below, revocation by the patient in writing, or termination of care by the provider. Revocation will not affect actions taken in reliance on this authorization prior to receipt of written revocation.

Authorization Expiration Date:

HIPAA Acknowledgment and Patient Rights

I understand that I have the right to request restrictions on the use or disclosure of my PHI; however, the provider and pharmacy are not required to agree to requested restrictions. I have the right to inspect and copy health information used or disclosed under this authorization, as permitted by law. I understand that treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing this authorization except where allowed by law.

I release the provider and pharmacy from any liability that may arise from the authorized disclosure of my health information. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by privacy laws.

Additional Instructions / Limitations

Certification

I certify that the information provided on this addendum is true and correct to the best of my knowledge. I authorize my healthcare provider to share the specified medication-related information with the named pharmacy for the purposes described. I understand that I may request a copy of this authorization for my records.

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