Starting June 1st, 2016, there is a charge for not showing up for scheduled appointments. $25.00 per appointments canceled without a 24-hour notice. Repeated cancellations or missed appointment will result in loss of future appointment privileges.
OTHER CHARGES INCLUDE:
$20.00 to have the blood drawn in the office.
$1.00 per page not exceeding $25.00 for Medical Records/Lab Results
$25.00 for Insurance Paperwork or Forms to be filled out.
CONSENT FORM FOR ePRESCRIBE PROGRAM
ePresctibing is a way for doctors to send electronically an accurate, error-free, and understandable prescription from the doctor's office to the pharmacy. The ePrescribe Program also includes:
• Formulary and benefits transactions - Gives the healthcare provider information about which drugs are covered by your drug benefit plan.
• Fill status notification - Allows the health care provider 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 Transaction - Provides the health care provider with information about your current and past prescriptions. This allows healthcare providers to be better informed about potential medication issues and to use that information to Improve safety and quality. 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 health care provider at PrimeHealth Physicians, LLC as well as other healthcare providers involved in your care and may include sensitive information Including, but not limited to medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and, other sensitive health information.
By signing this consent form you are agreeing that your provider at PrimeHealth Physicians, LLC 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 any effect on any action taken prior to receiving the revocation.
Understanding all of the above, I hereby provide Informed consent to PrimeHealth Physicians, LLC 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.