Healthcare Prescribers Update

HEALTHCARE PRESCRIBERS UPDATE

Use this form to request an addition, removal, or modification of prescriber information on the patient’s active prescribing records held by this practice. Completion of this form authorizes the practice to transmit updated prescriber data to pharmacies, insurers, and other entities as necessary for continuity of care. If signing on behalf of the patient, provide the representative relationship and attach documentation of authority where required.

Patient Information

Insurance Information

Current Prescriber on Record

Requested Update

Please indicate the nature of the update (select all that apply):

New / Updated Prescriber Information

Effective date of this update:

Prescribing Scope & Restrictions

Indicate authorizations or limits associated with the updated prescriber:

Medical History (for record completeness)

Authorizations and Acknowledgements

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 practice to update prescribing records, to share prescriber information with pharmacies, health plans, and other providers as necessary for treatment and medication fulfillment. I understand that this update does not change my health insurance coverage or benefits and that I may revoke this authorization at any time by providing written notice to the practice; however, revocation will not apply to disclosures already made in reliance on this authorization.

I acknowledge receipt of the practice’s privacy practices as they relate to prescribing and authorizations, and I consent to communications regarding prescriptions (including refill requests) to the contact information provided on this form.

This authorization will remain in effect until: or until revoked in writing by the patient or authorized representative.

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