Prescription Records Form PDF Details

At the heart of safeguarding personal health information, especially when it involves pharmacy records, stands a meticulously structured document - the Prescription Records Form. This particular form, an essential facet in the healthcare communication sphere, is used to permit the sharing of an individual's prescription details with designated parties. Originating from the desks of CVS/pharmacy, situated at One CVS Drive, Woonsocket, RI 02895, this authorization form facilitates a transparent, consensual transfer of medical data, crucial for various purposes that may range from personal record-keeping to facilitating medical care. It notably empowers the patient, or their duly authorized representative, to command the disclosure of their Patient Prescription Record (PPR), delineating the specifics of pharmacy services rendered. Through this provision, the individual not only authorizes the sharing of sensitive information but also grasps the latitude to revoke this consent at any given time, subject to conditions ensuring the preserver's accountability. The form further underscores the value of voluntary consent, guaranteeing that the act of authorization does not impinge upon the individual's access to pharmacy services. A highlight of this document is the emphasis on the security of shared data; however, it cautiously flags the risk associated with the recipient's obligation (or lack thereof) to uphold federal privacy standards. With a set expiry term, unless otherwise specified, and a provision for acknowledging the authority of a personal representative, the Prescription Records Form embodies a critical intersection of patient rights, privacy, and healthcare facilitation.

QuestionAnswer
Form NamePrescription Records Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescvs records request, cvs pharmacy disclosure authorization form, cvs pharmacy records, cvs prescription history

Form Preview Example

One CVS Drive, Woonsocket, RI 02895

Fax (401) 652-1593

CVS/pharmacy AUTHORIZATION FORM

PATIENT REQUESTING DISCLOSURE

Name: ________________________________________________________

Address: ________________________________________________________

Address: ________________________________________________________

Date of Birth _________________________

I hereby authorize CVS/pharmacy to disclose my Patient Prescription Record (PPR), reflecting information regarding my pharmacy services as set forth below:

1.My Patient Name: Address: Address:

sed to the following person(s):

___

___

______________________

2.I understand that I may revoke this authorization at any time by writing to CVS/pharmacy Privacy Office, 1 CVS Drive, Woonsocket, RI 02895, or fax to 1-401-652-1593, except to the extent that CVS/pharmacy has taken action in reliance on this authorization.

3.I understand that I am signing this Authorization of my own free will and that this authorization will not affect my ability to obtain treatment from the Pharmacy. I hereby state that this disclosure is at my request. A photocopy or facsimile of this signed authorization is as valid as the original and will be accepted.

4.I understand that if the person or entity that receives my PPR is not required to comply with the federal privacy regulations, the information described above may be redisclosed and would no longer be protected by those regulations.

5.

This Authorization will expire 6

is authorization

 

unless otherwise indicated here

 

 

 

 

 

 

 

 

 

_______________________________________

_________________________

 

Signature of Patient or Personal Representative*

Date

*To the patient’s personal representative, explain your authority to act on behalf of the patient: ________________________________________________________

___________________________________________________________________

_________________________________________________________________

__________________________________________________________________

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