Healthcare Pharmacy Update Form

Healthcare Pharmacy Update Form

Use this form to update pharmacy designation and authorize the release and transfer of prescription and medication-related health information to the designated pharmacy. Complete all applicable sections. Submission of this form constitutes a written authorization for the limited release of protected health information as described below and a lawful instruction to effectuate prescription transfers and communications with the pharmacy named.

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Pharmacy Designation

Current Pharmacy

Phone:    Fax:

New / Preferred Pharmacy

Phone:    Fax:

Prescription Transfer Instructions

I authorize transfer of my prescriptions as indicated below (check applicable box):

Transfer all active prescriptions Transfer only the medications listed below

Preferred method for transfer/communication (check all that apply):

Phone Fax Electronic prescription transmission Patient portal / secure message Other:

Medical / Medication Information

Authorization to Release Protected Health Information

I hereby authorize my healthcare providers and their business associates to disclose medication-related protected health information (PHI) to the pharmacy named above. PHI to be released may include prescription history, medication profiles, allergy information, relevant medical diagnoses and clinical notes necessary for safe dispensing, and insurance billing information. The purpose of this disclosure is continuity of care, prescription fulfillment, and coordination of medication therapy.

This authorization does not permit release of psychotherapy notes, if any, unless specifically indicated here:

Expiration: This authorization will expire on unless revoked earlier in writing. I understand that I may revoke this authorization at any time by delivering a written notice to my provider's medical records department, except to the extent that action has already been taken in reliance on this authorization.

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. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on my signing this authorization, except where allowed by law.

Communication & Message Authorization

I authorize the provider and pharmacy to leave messages regarding my prescriptions at the phone numbers provided and to communicate medication information with the following authorized persons (name and relationship):

Patient Certification

By signing below I certify that the information provided on this form is true and accurate to the best of my knowledge. I authorize the release and transfer of my medication-related records to the designated pharmacy and consent to the methods of communication selected. I understand the scope of this authorization and that I may revoke it in writing as described above. I acknowledge that the pharmacy may charge for dispensing or other services in accordance with applicable law and that this form does not alter my financial responsibility for medications.

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