E-prescribe Consent - South Coast Neurology

South Coast Neurology

ePrescribing Consent Form

Please fill in all Fields If they do not Apply Mark N/A

Patient Name

Patient ID

Date

South Coast Neurology Inc. has implemented ePrescribing in our office.

ePrescribing is a federally mandated initiative that requires all physicians prescribe in this manner by 2011

ePrescribing software sends prescriptions over the internet to your pharmacy in a safe, secure way, through the same technology used by credit card companies. This helps protect the privacy of your personal information.

ePrescribing software also lets your doctor see important information like drug interactions and your prescription history.

The benefit to you:

Less confusion over handwritten prescriptions or unclear phone calls
Reduced possibility of medical errors
Less chance of adverse drug reactions
Fewer trips to drop off at the pharmacy
A safer, faster, easier way to get your prescription filled

Patient Consent

I agree that South Coast Neurology Inc. may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payors for treatment purposes. Also, I understand that the pharmacy information I provided below will be kept in my records as the sole pharmacy I will use to obtain my medications from.

**CVS at 1109 State St will be selected automatically if you do not provide a pharmacy! **

Patient Name

Patient Signature

Witness

Pharmacy Name

Address

Telephone

Fax

This consent form is valid for one calendar year.

1919 State St, Suite 203 Santa Barbara, CA 93101 Tel: (805) 220-4300