MedOne Informed Consent and HIPAA Acknowledgement

MedOne Informed Consent and HIPAA Acknowledgement
- Company Name
- Patient's Name
  
  Patient First NamePatient Last Name
- Patient's Date of Birth
  
  MonthDayYear
  Date
- By checking the box(es) below, you confirm your consent to receive voicemail and/or SMS or secure email messages from NASH for important reminders regarding your prescription, including delivery/refill updates. You understand that SMS message and data rates may apply.
- By my signature below, I release that I understand:
  - A copy of my medical records will be requested from my current healthcare provider and stored by the Network of Advanced Specialty Healthcare (“NASH”) in a confidential manner in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
  - NASH may share my medical records with one or more prescribing provider(s) pursuant to HIPAA and the Medical Records Release Form.
  - I have voluntarily chosen to enter the NASH Specialty Pharmacy Program.
  - I have voluntarily chosen to receive the medication for my own personal use as a continuation of therapy.
  - I am of legal age and authorized to execute this consent form.
  - I will immediately notify my U.S. prescribing provider and/or my primary care provider of any medical conditions or significant physical or lifestyle changes which may adversely affect my personal health or the effectiveness of the medication.
  - I have received education about potential side effects of the medication, when they may occur, and when and where I should seek treatment. I understand that if I experience any side effects, I am responsible for following up with my primary care provider at my expense.
  - I have had the opportunity to ask questions about the medication, and all my questions have been answered. I understand the benefits and risks of the medication.
  I acknowledge I have received a copy of the Notice of Privacy Practices. Please remember to sign, date and submit this form!
- Patient or Guardian Name
  
  First NameLast Name
- Patient or Guardian Signature
- Today's Date
  
  MonthDayYear
  Date
Should be Empty: