1. I authorize registered pharmacists working at the pharmacy listed below to dispense up to a 90-day or lesser supply based on insurance coverage. This authorization to alter the daily supply does not allow changing of the directions of any prescription. The authorization to alter the quantity dispensed allows the pharmacy to provide the patient the best possible therapy based on their insurance benefits.
2. I authorize registered pharmacists working at the pharmacy listed below to remove an ingredient from a patient's compound prescription request and dispense it as a stand-alone commercial product. For example, a prescription sent for the following (lidocaine 5%/metronidazole 10%/nifedipine 0.5% Rectal Ointment) may be changed and dispensed as a separate individual prescription of commercial lidocaine 5% ointment alongside a compounded prescription consisting of metronidazole 10%/nifedipine 0.5% Rectal Ointment. This authorization allows the pharmacy to ensure patients receive their prescribed medications at what is financially best based on their insurance benefits.
3. I authorize registered pharmacists working at the pharmacy listed below to dispense Adjunct Therapy in accordance to the Adjunct Therapy Legend based on insurance coverage outlined in our alternate formulations legend. For example: corticosteroids, doxepin, lidocaine, diclofenac. I provide authorization to create a verbal prescription order for any adjunct therapy prescription in accordance with the Adjunct Therapy Legend. This authorization does not allow a change in directions or medication categories.
4. I have read the above authorization terms and agree to the indicated items moving forward with the Pharmacy. I do hereby consent and acknowledge my agreement with the Pharmacy regarding the terms set forth in this waiver. I understand that this consent shall remain in force from this time forward and that I may terminate this authorization at any point in time with a written request to do so. I acknowledge that for any patient that this authorization should not apply, I will inform the pharmacy in writing on the prescription.