Patient Authorization for Self-Pay

Patient Authorization for Self-Pay (HITECH)

For patients wanting to pay out-of-pocket for their prescription(s) despite insurance coverage
HITECH
Per the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, if a service is paid for entirely out-of-pocket by an individual, a covered entity must agree to a request that such individual’s Private Health Information (PHI) relating solely to that service NOT be disclosed to a health plan for purposes of payment or health care operations, unless the disclosure is required by law. [See 42 C.F.R. § 164.522(a)(1)(vi)]

By completing this form, you are agreeing to participate in Cost Plus, our self-pay program, and are requesting that St. Paul Corner Drug NOT bill your insurance plan when filling some or all of your prescriptions (as directed by you), even though you have prescription drug coverage that would cover the cost of these prescriptions.
Patient Information
Full name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization for Self-Pay
I certify that I currently have health insurance that includes prescription drug coverage.*
Initial here
Despite this coverage, I elect to participate in St. Paul Corner Drug's Cost Plus self-pay program. In accordance with HITECH legislation, I request that St. Paul Corner Drug NOT submit an insurance claim on my behalf for the filling of prescriptions as directed by me, and to instead fill any such prescriptions out of pocket via their Cost Plus program.*
Initial here
Please be aware that this is a generalized form for all Cost Plus participants; some patients will elect to fill all of their prescriptions out of pocket, while others will only use Cost Plus for the filling of some of their prescriptions. We will never fill a specific prescription via Cost Plus without your consent, and completing this form is NOT the equivalent of you giving us permission to do so.
Despite this coverage, I elect for the following prescription(s) to be paid for out-of-pocket and do NOT want St. Paul Corner Drug to submit an insurance claim for the filling of this/these prescription medication(s) on my behalf:
List the name of all medications you'd like to pay for out-of-pocket. Please list medication names as they appear on your prescription bottle (e.g., "Levothyroxine" (the generic version) instead of "Synthroid").
OR check this box:

I would like to pay out-of-pocket for ALL of my medications unless I tell St. Paul Corner Drug otherwise
I understand that any monies spent out of pocket on the above prescription medication(s) will NOT contribute to my health plan's deductible, out-of-pocket limits, or any other cost-share I may be subject to under my health insurance plan, unless otherwise permitted under the terms of my health plan.*
Initial here
Expiration
If you would like this authorization to expire on a certain date, please enter that date below. Otherwise, if left blank, this authorization will remain in effect indefinitely or until a request to terminate is received in writing from the Patient or a Patient Representative.
This authorization should remain in effect from the date this form is signed until:

MonthDayYear
Patient Attestation
By signing below, I agree to the above initialed terms and request that St. Paul Corner Drug fill the aforementioned prescription medication(s) without billing them to my health insurance plan.
Signature of Patient (or Patient Representative)*

Powered by Jotform SignClear
Patient Representative (if signed by Patient Representative)

First NameLast Name
Relationship to Patient (if signed by Patient Representative)
Proof of Power of Attorney (if signed by Patient Representative & applicable)

If you are Patient Representative completing and signing this form on behalf of a Patient for whom you hold Power of Attorney, please upload proof of Power of Attorney here
Cancelof
Should be Empty:

Patient Authorization for Self-Pay (HITECH)

HITECH

Patient Information

Authorization for Self-Pay

Expiration

Patient Attestation