By signing this form, I confirm that all the statements I have provided, including my responses to all questions are accurate and honest to the best of my knowledge and belief. I assent to provide the eligibility staff with any information needed to verify statements about my eligibility. I recognize that supplying false information could lead to disqualification and repayment. If my income or the number of individuals in my family should change, I will inform the eligibility staff.
Preventive Care (Write the date of your most recent)
Family History(Include Father [F], Mother [M], Sister [S], Brother [B], Grandfather [GF], Grandmother [GM])
Patient Mental Health Assessment
Drug and Alcohol Use and History
I have responded to all of the questions regarding my medical history and my present physical condition honestly and completely. I have informed the doctors or other designated health center personnel regarding any conditions I may have, which may influence my overall health care. It is my role to notify my provider if this information should change in the future. By signing below, I guarantee that I have answered and reviewed the complete four-page document. Any spaces left blank do not apply to me.
***By signing above, I certify that I have checked the whole two-page document and acquired clarification from the patient as needed. Any blank spaces in this history form must be lined through by the patient and initialed by the reviewing provider to establish that it is not relevant to the patient.***
Consent & Acknowledgment for Attaining e-prescribing History
Acknowledgment of Receipt of e-prescribing Information Sheet
By initialing, I accept that RX Team Home Health Care LLC has supplied me with its E-Prescribing Information Sheet, which discusses the purpose and specifics on how my prescriptions and prescription refill history will be managed electronically.
Terms of Consent
I am aware that providing RX Team Home Health Care LLC with my current and past prescriptions history will help the agency in verifying the safety of my prescriptions and lessening dangerous interactions with the other medications I may be taking.
I hereby consent to give RX Team Home Health Care LLC permission to acquire this medication history electronically from other healthcare organizations, which includes, but is not limited to, pharmacies.
I decline the option of supplying RX Team Home Health Care LLC with my current and past prescriptions history.
By signing below, I accept that I am accomplishing this consent of my own free will to consent as initialed above. I completely release RX Team Home Health Care LLC, their employees, Board Members, and agents (i.e., volunteers and students) harmless from any and all losses, damages, liabilities (joint or several), claims, litigation, payments, proceedings, and suits of any kind or nature whatsoever arising from out of my receipt of this service.
I am aware that this consent shall remain active until I retract my consent in writing at any time.
Consent for Review of Records for Research
RX Team Home Health Care LLC partakes in research studies, which include proven or experimental treatments. The RX Team Home Health Care LLC staff would like to examine your records to identify if you are eligible to be a part of current or future studies.
By signing this form, you are only signifying that you are willing to share the information found in your patient records with the RX Team Home Health Care LLC research staff. The lone objective of this information is to identify if you are eligible for a research study. You are not consenting to participate in a research study by signing this form.
This consent may be rescinded at any time, apart from the degree that action may already have been taken in reliance on it.