Cvs/pharmacy Authorization Form
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1LCS Job No.
One CVS Drive, Woonsocket, RI 02895
Fax (401) 652-1593
CVS/pharmacy AUTHORIZATION FORM
PATIENT REQUESTING DISCLOSURE
Name:
________________________________________________________
Address: ________________________________________________________
Address: ________________________________________________________
Date of Birth _________________________
I hereby authorize CVS/pharmacy to disclose my Patient Prescription Record (PPR),
reflecting information regarding my pharmacy services as set forth below:
1.
My Patient Prescription Record (PPR), may be disclosed to the following person(s):
Legal Copy Services, Inc.
Name:
______________________________________________________
3280 N. Evergreen Drive N.E. Grand Rapids, MI 49525
Address:
______________________________________________________
Phone (877)949-1313 Fax (877)949-2270
Address:
______________________________________________________
2.
I understand that I may revoke this authorization at any time by writing to
CVS/pharmacy Privacy Office, 1 CVS Drive, Woonsocket, RI 02895, or fax to
1-401-652-1593, except to the extent that CVS/pharmacy has taken action in
reliance on this authorization.
3.
I understand that I am signing this Authorization of my own free will and that this
authorization will not affect my ability to obtain treatment from the Pharmacy. I
hereby state that this disclosure is at my request. A photocopy or facsimile of this
signed authorization is as valid as the original and will be accepted.
4.
I understand that if the person or entity that receives my PPR is not required to
comply with the federal privacy regulations, the information described above may be
redisclosed and would no longer be protected by those regulations.
5.
This Authorization will expire 6 months from the dated signature on this authorization
unless otherwise indicated here _____________________________
_______________________________________ _________________________
Signature of Patient or Personal Representative *
Date
*To the patient’s personal representative, explain your authority to act on behalf of
the patient: ________________________________________________________
___________________________________________________________________
_________________________________________________________________
__________________________________________________________________
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Parent category: Business