CONSENT FORM FOR THE E-PRESCRIBE PROGRAM
Divisions of Florida Pediatric Associates, LLC have implemented e-prescribing as part of an on-going effort to improve your health care. E-prescribing refers to a system used to submit prescriptions electronically to a pharmacy of your choice. By eliminating paper, e-prescribing creates a more efficient and safer process for patients to access their medications. This electronic process aims to prevent prescription errors and improve patient safety. The ePrescribe Program may also include:
Formulary and benefit transactions – Provides information to your health care practitioner about which drugs are covered by your drug benefit plan.
Fill status notification - Allows your health care practitioner to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled.
Medication history transactions - Provides your health care practitioner with information about your current and past prescriptions to minimize potential medication issues and adverse medication events. Medication history data can indicate: compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy.
The medication history information would include medications prescribed by your Florida Pediatric Associates health care practitioner as well as other health care providers involved in your care. Medication history information may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information.
CONSENT
By signing this consent form you agree that your Florida Pediatric Associates health care practitioner may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.
You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it.
This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation.
Understanding all of the above, I hereby provide informed consent to Florida Pediatric Associates, LLC health care practitioner to enroll me in this ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.