Confidential Patient Enrollment Form

Thank you for interest in our medication management care program. This CONFIDENTIAL form and corresponding instructions have been provided for your convenience, and It should take you approximately 10 minutes to complete. Your information is kept strictly confidential and shared only between you and your physician to optimize coordination of care.
Please have the following information available:
1. All your current prescriptions, over-the-counter medications, herbals and supplements
2. Your primary physician’s name and contact information.

You will be contacted by a pharmacist in the next 2 hours, or based on your preferred availability indicated on the enrollment form. If you have any questions, please call our PharmD Live Help Desk at 202-765-1429

Demographic & Preferred Contact Information

Caregiver

Physician Information

Medication Allergies & Adverse Reactions

Example: Asprin
Example: Asprin
Example: Asprin
Example: Asprin
Example: Asprin
Example: Asprin

Current Medications & Medical Conditions

Example: Lipitor
Example: 10 mg
Example: Take 1 Tablet Daily
Example: High Cholesterol
Example: Lipitor
Example: 10 mg
Example: Take 1 Tablet Daily
Example: High Cholesterol
Example: Lipitor
Example: 10 mg
Example: Take 1 Tablet Daily
Example: High Cholesterol

Lifestyle

Attestation

I acknowledge receipt of the PharmD Live Notice of Privacy Practices as contained in this Enrollment Form, and I understand that a copy may be emailed to me, and is also available upon request by calling PharmD Live at 202-765-1429. I authorize PharmD Live’s designated employees to release to my health care providers (as identified above or otherwise learned by PharmD Live) any medication or other information about me which is related to my medical treatment and/or continuity of care, unless I state otherwise in writing. I further understand that all information contained on this enrollment form (e.g., phone numbers, email addresses, medical information) and otherwise revealed through my encounters with PharmD Live will remain strictly confidential.

NOTICE OF PRIVACY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY BY CLICKING HERE.

NOTICE OF PRIVACY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY BY CLICKING HERE.

PharmD Live is dedicated to maintaining the privacy of your health information. We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured health information.

This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45 CFR Part 164. We are required to abide by the terms of our Notice that is currently in effect.

  1. Uses And Disclosures We May Make Without Written Authorization.

We may use or disclose your health information for certain purposes without your written authorization, including the following:

Treatment. We may use or disclose your information for purposes of treating you. For example, we may disclose your information to another health care provider so they may treat you; to provide appointment reminders; or to provide information about treatment alternatives or services we offer. Payment. We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company or other payer to obtain payment for treatment.

Healthcare Operations. We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, we may use information to train or review the performance of our staff or make decisions affecting the practice.

Other Uses or Disclosures. We may also use or disclose your information for certain other purposes allowed by 45 CFR § 164.512 or other applicable laws and regulations, including the following:  To avoid a serious threat to your health or safety or the health or safety of others.  As required by state or federal law such as reporting abuse, neglect or certain other events.  As allowed by workers compensation laws for use in workers compensation proceedings.  For certain public health activities such as reporting certain diseases.  For certain public health oversight activities such as audits, investigations, or licensure actions.  In response to a court order, warrant or subpoena in judicial or administrative proceedings.  For certain specialized government functions such as the military or correctional institutions.  For research purposes if certain conditions are satisfied.  In response to certain requests by law enforcement to locate a fugitive, victim or witness, or to report deaths or certain crimes.  To coroners, funeral directors, or organ procurement organizations as necessary to allow them to carry out their duties.

  1. Disclosures We May Make Unless You Object.

Unless you instruct us otherwise, we may disclose your information as described below.  To a member of your family, relative, friend, or other person who is involved in your healthcare or payment for your healthcare. We will limit the disclosure to the information relevant to that person’s involvement in your healthcare or payment.

Your Rights Concerning Your Protected Health Information.

You have the following rights concerning your health information.

  • You may request additional restrictions on the use or disclosure of information for treatment, payment or healthcare operations.
  • You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable requests.
  • You may inspect and obtain a copy of records that are used to make decisions about your care or payment for your care, including an electronic copy.
  • You may request that your protected health information be amended.
  • You may receive an accounting of certain disclosures we have made of your protected health information.
  • You may obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically.

Changes To This Notice. We reserve the right to change the terms of this Notice at anytime, and to make the new Notice effective for all protected health information that we maintain. If we materially change our privacy practices, we will post a copy of the current Notice on our website. You may obtain a copy of the operative Notice from our  Privacy Officer.

Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. We will not retaliate against you for filing a complaint.

Contact Information. If you have any questions about this Notice, or if you want to object to or complain about any use or disclosure or exercise any right as explained above,

please contact:

Privacy Officer

Phone: 202-765-1429

Address: 1629 K street,Suite 300,Washington DC 20006

E-mail: privacyofficer@pharmdlive.com

Effective Date. This Notice is effective June 20, 2017