Healthcare Prescription Management Form

HEALTHCARE PRESCRIPTION MANAGEMENT FORM

This Prescription Management Form documents the prescribing instructions, patient authorizations, and release consents required to process, transmit and manage prescription therapy. The patient certifies that the information provided is accurate and authorizes disclosure of medical and insurance information to pharmacies, payors and health care providers as necessary to fulfill prescriptions. Controlled substances will be prescribed only in accordance with applicable law and prescriber policies.

Patient Information

Date of Birth:    Gender:

Emergency Contact

Relationship to patient:

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Insurance Phone:

Medical History & Current Medications

Prescription Details (Medication 1)

Strength:    Dosage Form:

Quantity to Dispense:    Refills Authorized:    Start Date:

Controlled Substance    Prior Authorization Required

Dispense As Written (DAW):    Generic Substitution Allowed:

Optional Additional Prescriptions (Medication 2)

Strength:    Quantity:    Refills:

Prescriber Information

NPI Number:    DEA Number:

Preferred Pharmacy

Authorization, Consent and Acknowledgment

By signing below, I authorize my prescriber and the practice named above to: (1) transmit prescriptions to the pharmacy I designate electronically or by fax; (2) release medical and insurance information to pharmacies, payors and their agents for purposes of dispensing and coverage determination; and (3) contact me regarding prescription therapy, prior authorization and medication management. I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

This authorization will expire on: unless an earlier date is specified in writing.

I acknowledge receipt of the practice's privacy notice and understand the uses and disclosures described therein with respect to prescription processing and health information exchange.

Patient consents to electronic prescribing:    Patient consents to pharmacy callbacks for clinical clarification:

Patient / Authorized Signer Certification

I certify that I am the patient named on this form or the lawful authorized representative of the patient and that the information provided is true and correct to the best of my knowledge. I understand that falsification of information may subject me to penalties under law and that this form does not replace prescription drug labeling or counseling provided by my pharmacist.

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