Healthcare Pharmacy Opening

HEALTHCARE PHARMACY OPENING

This Pharmacy Account Opening and Patient Consent Form establishes the patient's account with the pharmacy and authorizes the pharmacy to provide pharmaceutical services, communicate regarding prescriptions, and obtain necessary medication and insurance information as described below. Patient Name:

PATIENT INFORMATION

Male Female Other Prefer not to say

INSURANCE / PAYMENT

MEDICAL HISTORY

PHARMACY SERVICES & POLICIES

Preferred Service Type: In-Store Pickup Delivery Mail Order

By signing below, the patient authorizes the pharmacy to: (a) obtain medication history and prior dispensing records from other pharmacies and providers; (b) submit claims and receive payment from the listed insurance; (c) contact the patient regarding medication therapy, recalls, and refill reminders by the methods consented to below. The pharmacy shall maintain confidential records in accordance with applicable privacy laws.

I authorize the pharmacy to obtain my medication history.

I authorize assignment of insurance benefits to the pharmacy for prescription claims.

COMMUNICATION PREFERENCES

I consent to receive communications regarding my prescriptions, refill reminders, and health information via:

Phone Calls Text Messages Email Postal Mail

AUTHORIZED RELEASES

The patient may authorize the pharmacy to release protected health information to designated persons. List persons authorized to obtain prescription information on your behalf:

Emergency release authorization: Authorize release of limited information to emergency contact listed above

CONTROLLED SUBSTANCE POLICY

The pharmacy adheres to strict federal and state regulations regarding controlled substances. I acknowledge that I must present valid identification for controlled substance pick-up, that additional verification may be required, and that early refill requests may be denied in accordance with law and policy.

I acknowledge receipt of the controlled substance policy and understand the requirements.

TRANSFER / REFILL AUTHORIZATION

By signing this form I request and authorize the pharmacy to contact my current pharmacy to effectuate transfers and obtain prescription history as necessary to fill my prescriptions.

AUTHORIZATION DURATION

This authorization to disclose and receive protected health information and to bill insurance shall remain in effect until revoked in writing by the patient. This authorization shall expire on unless earlier revoked as provided above.

NOTICE OF PRIVACY PRACTICES / ACKNOWLEDGMENT

I acknowledge that I have been offered a copy of the pharmacy's Notice of Privacy Practices which describes how protected health information may be used and disclosed and how I can access this information. I understand that the pharmacy may contact me as permitted by law for treatment, payment, and health care operations.

I acknowledge that I received or was offered the Notice of Privacy Practices.

ADDITIONAL AUTHORIZATIONS

The patient understands and agrees that the pharmacy is authorized to act upon the instructions in this form and to rely on this authorization until revoked in writing. The patient agrees to notify the pharmacy of any changes to insurance coverage, address, or contact information. The pharmacy makes reasonable efforts to ensure accuracy of records but is not liable for errors resulting from inaccurate data provided by or on behalf of the patient.

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