Healthcare Prescriber Packet

HEALTHCARE PRESCRIBER PACKET

Prescriber Identification

NPI Number:    DEA Number:

State Medical License Number:    Issuing State:    License Expiration:

Practice / Facility Information

Office Phone:    Office Fax:

Prescribing Authority & Delegation

Prescriber Type: MD DO NP PA Other

Authorization for practice staff to transmit prescriptions, receive prior authorization status, and discuss protected health information with pharmacies and payers: Yes No

Prescription Transmission Preferences

Preferred transmission method: Electronic (eRx) Fax Phone (verbal orders)

Controlled Substances & Regulatory Compliance

I attest that I am authorized under state and federal law to prescribe controlled substances in schedules indicated below (select all that apply): Schedule II Schedule III Schedule IV Schedule V

I certify that I maintain current registration and records required by applicable controlled-substance laws and that prescriptions written by me will be issued only in the course of legitimate medical practice.

Authorization to Release Protected Health Information (PHI)

By signing below, the prescriber authorizes release of relevant protected health information to pharmacies, benefits managers, and their authorized agents for the purpose of verifying benefits, obtaining prior authorization, and coordinating dispensing of prescribed therapies. This authorization includes clinical notes, medication history, diagnostic results, and insurance information as necessary.

This authorization will remain in effect until:    Or until revoked in writing by the prescriber.

Acknowledgment of privacy notice and data handling policies: I acknowledge that I have read and understand the practice's privacy and data handling policies and authorize disclosures as outlined above.

Attestations & Certifications

1. The information provided in this packet is true and complete to the best of my knowledge. I understand that false statements may subject me to civil or criminal penalty under applicable law.

2. I authorize the verification of any information provided herein, including verification of license status, DEA registration, and disciplinary history with licensing authorities. I further authorize release of clinical PHI to facilitate patient care and medication dispensing consistent with applicable privacy laws.

3. I will notify the practice or facility promptly of any change in licensure status, DEA registration, or any restriction that affects my authority to prescribe.

Practice Attestation Signature

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