This Authorization Form is designed to meet the requirements of federal privacy regulations
issued by the Department of Health and Human Services at 42 CFR § 164.508.
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If you need assistance completing this form or have questions, please contact us at 443.290.6337 or enroll@ezrxmeds.com.
Fields marked with an * are required.
I give permission to my medical providers to use and disclose the following protected health information to;
EZ Scripts Pharmacy | 24340 Sperry Dr, 2nd Floor, Westlake, OH 44145 | Fax 270.682.0975.
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I hereby authorize my health care provider
(hereinafter referred to as “Entity”) to release my protected health information.
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The records I authorize to release includes all service dates from the start of my injury on .
PURPOSE: The protected health information is used or disclosed for workers’ compensation benefits and reimbursements for pharmacy services rendered.
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EXPIRATION DATE: This authorization to disclose protected health information expires one year after this execution.
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VOLUNTARY AUTHORIZATION: I may refuse to sign this authorization. Treatment, benefits, and payment cannot be conditioned on my signing of this authorization form.
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INSPECTION: I may inspect or copy the protected health information to be used or disclosed under the authorization. I may inspect my protected health information without signing this form.
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REVOCATION: I may revoke this authorization in writing at any time by sending a notification to EZ Scripts Pharmacy, 24340 Sperry Dr, 2nd Floor, Westlake, OH 44145.
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My notice of revocation will not apply to actions taken by the requesting person/entity prior to the date they receive my written request to revoke authorization.
INFORMATION TO BE DISCLOSED​
Thank you for completing and submitting your Authorization for the Release of Health Information to EZ Scripts Pharmacy.
