Consent to Treatment, Assignment of Benefits & Authorization to Release Information
I acknowledge I have received a copy of MCC’s Notice of Privacy Practices and I understand that I have a right to review these privacy practices before signing this consent form.
I hereby consent to treatment by Minnesota Community Care (MCC). I also assign MCC any insurance, or third party benefits available for health care services provided to me.
With the exception of Health Start School Based Care Patients and MCC Homeless Patients, I understand that I am responsible for any balance that remains on my account that is not paid for by insurance or other sources of funding.
I authorize the exchange / release of or access to of any protected health information, via paper or electronic review by MCC. I also authorize the exchange / release of or access to of any protected health information, via paper or electronic review by MCC with any providers, hospitals and / St. Paul Area Public Schools / or specialist(s) to whom I may receive care from or be referred for care to coordinate my care, and to get complete and up-to-date information to each of the providers who treat me or to my insurance company or authorized third parties to determine benefits and secure payment for services provided to me. I also authorize my other health care providers to release my information to MCC for these purposes.
Some of your records related to substance use disorder diagnosis and treatment are protected from disclosure by the Federal Regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 CFR Part 2, also known as “Part 2”. These records may only be disclosed by your Part 2 Provider with your written consent unless otherwise provided for by Part 2. By signing below, you are consenting to the disclosure of your substance use disorder records within Minnesota Community Care.
E-PRESCRIBING / MEDICATION HISTORY CONSENT FORM
E-Prescribing is defined as a physician’s ability to electronically send an accurate error free and understandable prescription directly to a pharmacy from the point of care. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. E-Prescribing greatly reduces medication errors and enhances patient safety. The Medicare Modernization Act of 2003 listed standards that have to be included in an e-Prescribe program. These include:
1. Electronically sending prescriptions and receiving refill requests: Allows the prescriber to electronically send prescriptions to the pharmacy, allows the prescriber to electronically receive refill requests from the pharmacy, and allows the prescriber to notice from the pharmacy telling them if the patient’s prescription has been picked up, not picked, or partially filled.
2. Formulary and benefit transactions: Gives the prescriber information about which drugs are covered by the drug benefit plan.
3. Medication history transactions: Provide the physician with information about medications the patient is already taking to minimize the number of adverse drug events.
By signing this consent form, you are agreeing that Minnesota Community Care clinics can request/send your prescription medication history from/to other healthcare providers and/or pharmacies and/or pharmacy insurers for treatment purposes.
Understanding all of the above, I hereby provide informed consent to Minnesota Community Care to enroll me in its e-Prescribe Program. I have had a chance to ask questions and all of my questions have been answered to my satisfaction.
Your signature below indicates you understand and agree to the above statements and you have received Minnesota Community Care’s Notice of Health Information Privacy Practices. Without your signature, we cannot provide health care services.
I understand that this authorization is revocable upon written notice to the office where the original authorization is retained, except to the extent that action has already been taken on this authorization. Minnesota Community Care may not condition the provision of treatment, payment, or eligibility for benefits on the provision of this authorization.