INFORMED CONSENT
UAB PHARMACY SERVICES
I understand that I am to receive my therapy at home or through UAB Outpatient Services . My medication ( s ) and supplies will be provided by UAB Pharmacy Services , I and / or my caregiver have been trained in the care and techniques for use associated with my access device , equipment , and medications , or arrangements have been made for my treatments to be administered by a trained professional . I have been provided a schedule for administration of my medication , and I have been instructed on how and when to request supplies , if needed .
Possible side effects of my medication ( s ) and therapy have been explained to me . I have been instructed on how and to whom to report unusual signs and symptoms . I have also been instructed on how to report problems associated with equipment or supplies .
If I should require home nursing care and / or laboratory testing , I have been informed of available services . I have also been informed that I may choose a pharmacy or home infusion service other than UAB Pharmacy Services .
I understand that I must provide a means of communication , usually by telephone , so that my progress can be monitored . I must provide an address or arrange for pick-up of medications and supplies from the pharmacy location .
DISCLOSURE OF INFORMATION I agree that the results of my treatment , including laboratory tests may be communicated to health-care providers associated with my care . I also understand that my medical record may be reviewed by medical students , pharmacy students , accreditation body representatives and regulatory inspectors as a part of normal operating procedures and quality improvement activities .
I authorize the pharmacy staff to review my medical history , prescription formulations , and insurance information as they relate to my care . This information will be solely used on my behalf for the purpose described . This information is not to be made available for any other use without my written consent .
ASSIGNMENT OF BENEFITS I authorize payment of prescription and medical benefits to UAB Pharmacy Services , for services rendered . I further agree to pay all charges connected with this treatment not covered by any insurance I may have and understand insurance coverage does not release me of the obligation of payment to UAB Pharmacy Services . If unable to pay for services rendered , it is my responsibility to arrange counseling through Social Services and receive information on available options . I will receive an invoice or receipt for each delivery . My original signature will be on file granting consent for the continuation of my therapy .
If a Medicare patient , I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct . I authorize release of all records required to act on this request . I request that payment of authorized benefits be made on my behalf . I authorize any holder of medical or other information about me to release to the health care financing administration and its agents any information needed to determine these benefits for related services .
If I have any questions pertaining to my treatment the pharmacy staff will be glad to answer them . If I have any medical emergencies , I have been instructed to contact my physician through UAB Hospital paging ( telephone number 205-934-3411 ). Pharmacy-related emergencies should be directed to UAB Hospital paging ( 205-934-3411 ) and they will contact the pharmacist on call .
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