Pharmacy Consent Form

By signing this Appointed Pharmacy Consent Form, the client authorizes a provider to disclose to the pharmacy that he or she is being treated for a substance use disorder; the pharmacy is also authorized to contact Miami Valley Recovery, LLC to discuss treatment.

Name*

First Name Middle Name Last Name

I do hereby consent Miami Valley Recovery, LLC to disclose my substance use disorder treatment to employees of the pharmacy specified below. Treatment disclosure most often includes, but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my prescriptions directly to the pharmacy.

Agree to allow pharmacist to contact provider listed above to discuss my treatment if necessary so that my prescriptions can be filled and either delivered to Miami Valley Recovery, LLC or picked-up by employees of the same.

I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken on reliance on it. This consent will last while I am being treated for substance use disorder by the provider specified above unless I withdraw my consent during treatment. This consent will expire 90 days after I complete my treatment, unless the provider specified above is otherwise notified by me.

I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.

I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.

Signature*

Clear

Date

Signature

Clear

Date

Pharmacy Name*

Pharmacy Phone*

Area Code Phone Number

Pharmacy Address (if you don't know leave blank)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Confidentiality of Alcohol- and Drug-Dependence Client Records

The confidentiality of alcohol- and drug-dependence Client records maintained by this practice/program is protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a client attends the practice/program, or disclose any information identifying a client
as being alcohol- or drug-dependent unless:

1. The patient consents in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or practice/program evaluation.

Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.

Federal law and regulations do not protect any information about a crime committed by a client either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime.

Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

This release can be revoked at any time with expressed written consent from the client.

This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to who it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecuted any alcohol or drug abuse patient.

Pharmacy Consent Form

APPOINTED PHARMACY CONSENT

Appointed Pharmacy: