HIPAA Secure Medical and Health Information Form

HIPAA Secure Medical and Health Information Form
- Patient First Name*
- Patient Last Name*
- Cell Phone*
Address*
Street Address City State ZIP Code
- Email Address*
- Date of Birth*
  Date Format: MM slash DD slash YYYY
Allergies:

- Are you pregnant?*
- How far along are you (how many weeks)?*
- Are you HIV positive?*
- Are you Hepatitis C positive?*
Current Medications (click the + button to add more rows)
Medication Strength Frequency Physician
Medical/Healthcare Information Authorization: HIPPA
- Patient Full Name:*
- Social Security Number:*
I request and authorize CompreCare Pharmacy to release, discuss medical related healthcare issues or pickup my medication to the below listed:
- Authorized Individuals Name*
- Authorized Individuals Phone Number*

This request and authorization apply to (check all that apply):*
- Healthcare Information relating to the following therapy or condition.
- All Healthcare Information
Consent revokation 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 COMPRECARE SPECIALITY 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.
CompreCare Notice of Privacy Practices*
By checking this box I agree to and understand the CompreCare Notice of Privacy Practices
Your health information is contained in a medical record that is the physical property of Pharmacy Associates, Inc. dba CompreCare. Pharmacy Associates, Inc, dba CompreCare 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 CompreCare have certain rights and restrictions relating to the uses and disclosure of your information. Among its obligations, Pharmacy Associates, Inc. dba CompreCare 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 COMPRECARE’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 my buprenorphine prescriptions (examples: Subutex, Suboxone, Buprenorphine/Naloxone, etc.) with CompreCare Pharmacy:
1. I will keep my medication in a safe and secure place away from children (e.g., in a lock box or locked cabinet).

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.

3. I will keep my doctor informed of all my medications (including herbs and vitamins) and medical problems and will notify the pharmacy of any changes.

4. 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 life-threatening or serious side effects, and I agree to consult with my doctor or the pharmacy if I have questions about other medications I use or have used in the past.

5. I understand that I may not obtain buprenorphine or other opioid prescriptions from multiple doctors or fill my
prescriptions with multiple pharmacies.

6. 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 CompreCare Pharmacy and will be reported to my doctor and the authorities.

7. 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.

8. 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.
Who will be signing this form?*
Date*
Date Format: MM slash DD slash YYYY

Medication	Strength	Frequency	Physician

HIPAA Secure Medical and Health Information Form

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