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CONSENT TO MAIL MEDICATIONS TO MY HOME GENERAL INFORMATION

GENERAL INFORMATION

Patient understands Neuroich Orthopaedics Spine & Neurology (“Provider”) is licensed to dispense certain medications (“Medications”). Patient understands Provider is willing to mail Medications to Patient’s home address via First - Class Mail. Patient understands there is a risk, however, that: (i) someone may steal Medications out of Patient’s mailbox, (ii) a family member or other person authorized to collect the mail from Patient’s mailbox may wrongfully take Medications, (iii) Medications may get lost or stolen in transit from their office to Patient’s mailbox, or(iv) Medications may be delivered to the wrong address. Additionally, a collateral risk of mailing Medications is that Patient’s Protected Health Information(PHI) is discovered by an unauthorized party. Patient understands Provider is not responsible if sending Medications results in an unauthorized person seeing Patient’s PHI or obtaining Medications. Knowing these risks and accepting the liability and responsibility for same, Patient agrees and authorizes Provider to mail Patient’s Medications to Patient’s home address.

ACCEPTANCE, CONSENT, AND WAIVER

Patient agrees to allow Provider to mail Patient’s prescriptions directly to the address Patient provided. This mailing will include Patient’s PHI, such as Patient’s name and the medication that Patient am taking and may include other sensitive facts about Patient’s health. Patient understands that if another person accesses Patient’s prescription, that person will see Patient’s PHI. If Patient do not want to accept the risk that someone may take Patient’s prescription and/ or access Patient’s PHI, Patient should not agree to allow Provider to mail Patient’s prescriptions to Patient.

Patient accepts these risks and agrees that Provider may mail Patient’s prescriptions to Patient via First-Class Mail. Patient agrees to inform Provider immediately if Patient’s address changes. Patient will not hold Provider responsible if Patient’s PHI is seen by an unauthorized person or Patient’s medications are taken/ obtained by an unauthorized party. Patient RELEASES, WAIVES, DISCHARGES AND PROMISES NOT TO SUE OR BRING ANY CLAIM OF ANY TYPE AGAINST PROVIDER FOR LOSS, DAMAGE, INJURY, OR LIABILITY RELATING TO THE MAILING OF MY MEDICATIONS TO MY DESIGNATED ADDRESS.

This form gives you the facts and risks involved in receiving Patient’s Medications by mail. By accepting this form, Patient confirms that Patient has read, understands, and agrees with these Terms of Use for receiving Patient’s Medications by mail.

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