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Patient Authorization for ePRESCRIBE
ePrecribing is a physician's ability to electronically send an accurate, error free, and understandable prescription directly to a
pharmacy from the practice. ePrescribing greatly reduces medication errors and enhances patient safety. Understanding all of
the above, I hereby authorize the physician and/or staff of SCEUCto enroll me in the ePrescribe Program.
Patient signature ____________________________________________ Date ___________________________
Patient Authorization for PHARMACY BENEFITS MANAGER
I authorize the physician and/or staff of SCEUCto request and obtain my prescription medication history from other healthcare
providers, the pharmacy benefit manager and/or any third-party pharmacy payors for treatment purposes.
Patient signature ____________________________________________ Date ___________________________
Patient Authorization for MEDICARE PATIENTS
I authorize the physician and/or staff of SCEUC to release to the social security administration, Health Care Financing
Administration or its intermediaries or carriers any information needed for this or any Medicare claim. I permit a copy of this
Authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the
party who may cause Medicare payment information to cross over automatically to my supplement insurer. I understand that I
am financially responsible for any services deemed non-covered by Medicare.
Patient signature ____________________________________________ Date ___________________________
Patient Authorization for PPO and HMO PATIENTS
I authorize the physician and/or staff of SCEUCto release to my insurance company or its representative any information
including the diagnosis and records of any treatment or examination rendered to me during medical or surgical care. I authorize
and request my abovenamed insurance company to pay directly to Safe Care Express Urgent Care, PLLC the amount due for
medical or surgical services. I understand that I am financially responsible for any services deemed non-covered by my
insurance company.
Patient signature ____________________________________________ Date ___________________________
Patient Authorization for ALL PATIENTS
I understand that I am financially responsible for services in the office and that refunds from services charged on a credit card
will be returned to the same credit card. Furthermore, I also understand that any account balance that is not paid may be sent
to a collection agency. Should any delinquent account balance be referred to a collection agency, I understand that I will be
financially responsible for any and all cost and fees relating to the collection of my debt. I also authorize my physician and
SCEUCto photograph me for medically related documentation purposes.
Patient signature ____________________________________________ Date ___________________________
If a patient requires an accommodation for their appointment, the individual or his/her representative must notify SCEUCof the
needed accommodation one week prior to the first new patient appointment. Subsequent appointments also require one week’s
notice. Under the American with Disabilities Act, “Providers are responsible for incurring all costs of providing reasonable aid
and cannot pass that charge onto the patient or to his/her insurance company.”
If a patient who has requested
accommodations does not provide a minimum of 24 hours’ notice to cancel the appointment or does not show to the scheduled
appointment, all charges incurred by SCEUCis the patient’s responsibilities.
Patient signature ____________________________________________ Date ___________________________
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
Notice to patients: We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use
and/or disclose your health information. Please sign this form to acknowledge receipt of the notice. You may refuse to sign the
acknowledgement, if you wish. I acknowledge that I have received a copy of the SCEUC’SNotice of Privacy Practices.
____________________________________ _________________________________________ _______________
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