Healthcare Rx Form

HEALTHCARE RX FORM

Patient Information

Patient Name:

Date of Birth:   Gender:

Phone:   Email:

Insurance Information

Policy Number:   Group Number:

Medical History & Allergies

Pregnancy / Breastfeeding status: Pregnant    Breastfeeding

Prescription Details

Medication 1

Drug Name:   Strength:

Dosage Form / Route:   Quantity:   Refills:

Dispense As Written / Substitute: Dispense as Written (No substitution)    Generic substitution permitted

Medication 2 (optional)

Drug Name:   Strength:

Dosage Form / Route:   Quantity:   Refills:

Dispense As Written / Substitute: Dispense as Written    Generic permitted

Medication 3 (optional)

Drug Name:   Strength:

Dosage Form / Route:   Quantity:   Refills:

Dispense As Written / Substitute: Dispense as Written    Generic permitted

Pharmacy and Authorization

Pharmacy Phone:   Pharmacy Fax:

ICD-10 / Diagnosis Code:   Diagnosis Description:

Prior Authorization Required: Yes

Notices, Warnings & Authorizations

I authorize the pharmacist to dispense the medication(s) as prescribed above and to contact the prescriber's office for clarification as necessary. The prescriber certifies that the medication(s) prescribed are medically necessary for the patient named herein and that the prescriber will document the medical rationale in the patient's record.

Controlled Substances: If any medication listed is a controlled substance, patient agrees to comply with applicable law regarding monitoring, dispensing, and safe storage. Misuse or diversion of controlled substances is a criminal offense and may result in legal consequences and termination of treatment.

Electronic Transmission: This prescription may be transmitted electronically to a pharmacy of the prescriber's choice unless otherwise indicated. The prescriber may write a paper prescription at their discretion.

Pharmacy Release Authorization: The patient authorizes release of medication history and insurance information to the prescriber and pharmacies for the purpose of dispensing and coordinating care.

Acknowledgment of Privacy Practices: I acknowledge receipt of the Notice of Privacy Practices and consent to the use of my protected health information for treatment, payment and health care operations as provided therein.

Prescriber Information

Professional License / State:   DEA Number:

NPI:   Office Phone:

Certifications & Signatures

By signing below, the prescriber certifies that the information contained in this prescription is accurate to the prescriber's knowledge and that the medication(s) are medically necessary for the patient. The prescriber further certifies that they are authorized to prescribe medications in the issuing jurisdiction and will maintain appropriate clinical documentation.

Sign Now