New Patient Registration Packet

Family Care Clinic ePrescribing Consent Form

ePrescribing is now being mandated by Congress for the purpose of providing error free, accurate prescriptions to a pharmacy from a physician. The Medicare Modernization Act of 2003 listed standards that have to be included in an ePrescribe program. These include:

Formulary and benefit transactions - Gives the prescriber information about which drugs are covered by the drug benefit plan.
Medication history transactions - Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.
Fill status notification - Allows the prescriber to receive an electronic notice from the pharmacy telling them if the patient's prescription has been picked up, not picked up, or partially filled.

By signing this consent form you are agreeing that the Family Care Clinic can request and use your prescription medication history from other healthcare providers and or/third party pharmacy benefit payors for treatment purposes.

Understanding the above, I hereby provide informed consent to the Family Care Clinic to enroll me in the Prescribe Program.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Patient's Printed Name

Patient's DOB

Patient/Parent Signature

Today's Date

Patient Registration

Patient Information

Patient's Full Legal Name:

Race:

DOB:

Age:

SS #:

Complete Mailing Address:

City:

Zip:

Complete Residential Address (if different):

Cell Phone:

Home Phone:

Email:

In case of Emergency, please Notify:

Phone:

Relationship to Patient:

Fill out this section if patient is not the insurance policy holder.

Name of Insured:

Insured's DOB:

Insured's SS #:

Insured's Phone:

Insured's Address:

City:

Zip:

Patient's Responsible Party

This section must be filled out if the PATIENT IS A MINOR AND the patient's responsible party is not the insured.

Name:

Complete Mailing Address:

City:

Zip:

Home Phone:

Other Phone:

Responsible Party Agreement

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED, REGARDLESS OF INSURANCE COVERAGE.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

SIGNATURE:

DATE:

Text/Email Message Consent

I hereby give consent to receive text message/email appointment reminders and correspondence from my healthcare provider. I understand that consent is not a condition of receiving service. I understand and agree that any text message I receive may be sent by autodialer.

Phone number to receive text messages:

Email:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature of patient/guardian

Name of patient/giuardian

Date

Patient Preference Regarding Communication of Health Information

I. Who to Contact

I hereby give permission to the Family Care Clinic to disclose and discuss any information related to my medical condition(s) to/with the following family member(s), other relative(s) and/or close personal friend(s):

New Patient Registration Packet

Family Care Clinic ePrescribing Consent Form

Patient Registration

Patient's Responsible Party

Responsible Party Agreement

Text/Email Message Consent

Patient Preference Regarding Communication of Health Information

CONSENT FOR TREATMENT

Acknowledgement of Receipt of Notice of Privacy Practices

Financial Statement for the Family Care Clinic

Patient History Form