HIPAA Secure Patient Enrollment Form

Patient Medical History

Allergies:

Current Medications

Medication	Strength	Frequency	Physician

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Medical/Healthcare Information Authorization: HIPAA

I request and authorize PursueCareRx Pharmacy to release, discuss medical related healthcare issues or pickup my medication to the below listed:

Consent revocation acceptance.*

By checking this box I agree to and understand the statement about revoking consent below.

I understand that I may revoke this consent at any time, and that upon fulfillment of the above stated purpose or lapse of twelve months from the date of the signature, whichever comes first, this consent will automatically expire without my express revocation, but that revocation may not be applied retroactively once the information has been released in good faith. I do not authorize further release to any other third party. I understand that PURSUECARERX PHARMACY, and its staff, employees and directors cannot be responsible for confidentiality of information disclosed after said information has been released pursuant to this responsibility or liability that may arise from this authorization.

PursueCareRx Notice of Privacy Practices*

By checking this box I agree to and understand the PursueCareRx Notice of Privacy Practices

Your health information is contained in a medical record that is the physical property of Pharmacy Associates, Inc. dba PursueCareRx. Pharmacy Associates, Inc, dba PursueCareRx uses health information about you for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive. Under federal HIPAA regulations, you and Pharmacy Associates, Inc. dba PursueCareRx have certain rights and restrictions relating to the uses and disclosure of your information. Among its obligations, Pharmacy Associates, Inc. dba PursueCareRx is required to maintain the privacy of protected health information; provide you notice of its legal duties and privacy practices; notify you if we are unable to agree to a requested restriction on how your information is used or disclosed; accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and obtain your written authorization to use or disclose your health information for certain defined reasons. THE FULL TEXT OF PHARAMCY ASSOCIATES, INC DBA PURSUECARERX’S PRIVACY NOTICE HAS BEEN PROVIDED TO YOU ALONG WITH OTHER NEW PATIENT INFORMATION, THE NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY.

Patient contract terms for filling Buprenorphine prescriptions*

By checking this box I agree to accept the following patient contract terms for filling buprenorphine prescriptions, if/when applicable, with PursueCareRx Pharmacy (examples: Subutex, Suboxone, Buprenorphine/Naloxone, etc.):

1. I will keep my medication in a safe and secure place away from children (e.g., in a lock box or locked cabinet). I understand that the medication is my responsibility, and that I must take full responsibility for accounting for my medication at all times.

2. I will take the medication exactly as my doctor prescribes. If I want to change my medication dose, I will speak with the doctor first. Taking more than my doctor prescribes is medication misuse. My doctor will be notified by the pharmacy if I am suspected of misusing my medication. Prescriptions for quantities outside of typical treatment guidelines will not be filled.

3. I understand that I cannot take certain other medications such as benzodiazepines (drugs like Valium®, Klonopin® and Xanax®), alcohol or other opioid medications as this may result in serious/life-threatening side effects.

4. I understand that I may not obtain buprenorphine or other opioid prescriptions from multiple doctors or fill my prescriptions with multiple pharmacies. I understand that “new” prescriptions are not to be filled “early,” except when authorized by prescriber in emergency situations.

5. I understand that it is illegal to give away or sell my medication – this is diversion. If I do this, I understand that my prescription may no longer be filled at PursueCareRx Pharmacy and will be reported to my doctor and the authorities.

6. I understand that I must submit to drug testing as instructed by my doctor and will comply with my doctor’s treatment plan and testing as necessary. I understand that I may be required to attend therapy/counseling as part of my doctor’s treatment plan and will do so according to my doctor’s instruction.

7. I understand that I must provide the pharmacy with a form of government issued photo identification for drop-off/pick-up of all new and refilled prescriptions, as required by state and federal regulations. I understand that I must provide my current prescription insurance information to the pharmacy.

8. I understand that I should drop off and pick up my own prescription (no representatives).

9. I understand that I should bring my current labeled buprenorphine-based medication prescription container, whether containing remaining medication or empty, with me every time I come to the pharmacy to pick up a new or refill prescription for a buprenorphine-based medication.

10. I understand that I must NEVER use inappropriate language or inappropriate behavior, either while in the pharmacy or on a phone call. I understand these actions may result in my immediate dismissal from pharmacy services.

11. I understand that I will not take any illegal substances or any medication not prescribed to me and/or monitored by my pharmacist.

Patient Enrollment Form

Patient Contact Information

Patient Insurance Information

Patient Medical History

Medical/Healthcare Information Authorization: HIPAA

I request and authorize PursueCareRx Pharmacy to release, discuss medical related healthcare issues or pickup my medication to the below listed:

Release and Waiver of Liability, Assumption of Risk, and Indemnity