ANCZ01 E Prescribe Consent Form

E-PRESCRIBING CONSENT FORM

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Patient ID #

ePrescribing is defined as a physician’s ability to electronically send an accurate, error free and understandable prescription directly to a pharmacy from the point of care. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. ePrescribing greatly reduces medication errors and enhances patient safety. The Medicare Modernization Act (MMA) of 2003 listed standards that have to be included in an ePrescribe program. These include:

FORMULARY AND BENEFIT TRANSACTIONS: Gives the prescriber information about which drugs are covered by the drug benefit plan.
MEDICATION HISTORY TRANSACTIONS: Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.
FILL STATUS NOTIFICATION: Allows the prescriber to receive an electronic notice from the pharmacy telling them if the patient’s prescription has been picked up, not picked up or partially filled.

By signing this consent form you are agreeing that Anchorage & Valley Radiation Therapy Centers treating Providers can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes. Understanding all the above, I hereby provide informed consent to Anchorage & Valley Radiation Therapy Centers to enroll me in the ePrescribe program. I have had the chance to ask questions and all my questions have been answered to my satisfaction.

MEDICATION REFILL POLICY

In order to provide the best care possible, we ask that patients allow 24 hours for our medical staff to process refill requests. Patients are requested to please plan ahead and submit requests well before they run out of their medications so that the appropriate records can be reviewed by the attending physician in order to ensure continuity of care. This is particularly important at the end of the workweek since our clinic is not open over the weekend.
Clinic staff will make every effort to process refill requests as quickly as possible.
If you will be using a mail order pharmacy or your medication requires a prior authorization, please allow extra time so you do not run out while you are waiting.
If you have any questions about your medication, please talk to a registered nurse or your physician.
If you have changed your pharmacy of choice, please let us know so that we can route your prescription to the correct pharmacy.

Preferred Pharmacy:

Preferred Pharmacy Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

By signing below I understand, agree, and accept the policy written above.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient Signature*

Date

Parent/Guardian Signature (if required)

Date