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Prescription History Request Authorization Form This form should be used by the member or his/her Personal Representative to request printouts of the member's prescription history. A Personal Representative is someone who has legal authority to make healthcare decisions on behalf of the member. A separate authorization form is required for each member. Please fill out the following information, and complete 1 and 2 below: Name of Member/Individual: Address: Date of Birth: Phone:

1. I authorize the disclosure of my health information, as described below. Prescription history for time period ______________________ (i.e. 01/01/07- 12/31/07) I understand that this health information may include HIV-related information and/or information relating to substance abuse treatment and/or mental health diagnoses and treatment and that by signing this form, I am authorizing such information to be disclosed. 2. Please complete the following, as applicable: I authorize WellDyneRx to disclose the information described above in one of the three ways described below (please check one and provide the needed information): Please fax my information to the following PRIVATE fax number: _______________ Please email my information in a zipped file. I have win zip in order to open up the document. Please send it to the following email address: ______________________________. I understand that once you send me the file I must receive a phone call from a WellDyneRx representative to give me the password to open up the document. Please call me at the following number: _____________________________. Please mail my information to me at the address listed on my file. Please mail my information to a different address I have listed below: ____ _

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This information is being disclosed at my request for my own purposes. I understand that I may revoke this Authorization in writing at any time, except to the extent that WellDyneRx has already taken action in reliance on this Authorization, by submitting a written statement of revocation to the Privacy Representative. I understand that I am not required to sign this Authorization as a condition of treatment, payment, enrollment or eligibility for benefits.

By signing below, I acknowledge that I have read and understand this Authorization form.

Signature of Patient or Patient's Personal Representative


If signed by the Patient's Personal Representative, please print name and describe relationship to patient or other authority to act: Name Relationship to Patient

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Microsoft Word - Prescription History Request.doc

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