E-Prescribing Plan

E-Prescribing

E-prescribing is an optional convenience and security service and is NOT covered by insurance. E-prescribing is NOT available for patients with MEDICARE and MEDICAID Insurance.

The fee is $50 every 6 months and is billed automatically on a recurring basis. This fee is non-refundable with no exceptions. It is the patient’s responsibility to cancel or notify our office requesting cancellation of the subscription if it is no longer needed. Failure to cancel does not stop billing or qualify for a refund.

Patient's Name*

Jane Doe

Date of Birth*

MonthDayYear

Email

example@example.com

Cell Phone #*

Area CodePhone Number

E-Prescribing*

E-Rx Pain($50.00 for each six months)

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Today's Date

Date