(Note: If you need referrals in the future, you need to identify your doctors here)

E- Prescribing is defined as a physician's ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy from the point of care. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. E-Prescribing greatly reduces medication errors and enhances patient safety. The Medicare Modernization Act (MMA) of 2003 listed standards that have to be included in an ePrescribe program. These include

By signing this consent you are agreeing that West Orlando Internal Medicine can request and use your prescription medication history from other healthcare providers and/ or third party pharmacy benefit payors for treatment purposes

1. Formulary and benefit transactions - Gives the prescriber information about which drugs are covered by the drug benefit plan.
2. Medication History Transaction- Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.
3. Fill status notification - Allows the prescriber to receive an electronic notice from the pharmacy telling them if the patient prescription has been picked up, not picked up, or partially filled.

Understanding all of the above, I hereby provide informed consent to West Orlando Internal Medicine to enroll me in the E-Prescribing Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

I have read and acknowledge the financial policy at West Orlando Internal Medicine.

I hereby authorize my insurance carrier, attorney or any third-party to pay directly to West Orlando Internal Medicine (WOIM) all charges submitted for services incurred by me. I understand I will be responsible for any and charges not paid for by my insurance company. I authorize West Orlando Internal Medicine to release information concerning my medical condition to my insurance company, employer, hospital, physician or attorney for the purpose of processing a claim. I assign payment directly to the providers at WOIM which may be due for me from the Medicare program or any other insurance company, including supplemental insurance, which may cover in whole or in part medical services which I have received. This authorization and assignment shall be valid until I notify West Orlando Internal Medicine in writing of the cancellation. A photocopy of this authorization shall be valid as the original copy.

My signature on this document acknowledges that I have read the West Orlando Internal Medicine, LLC HIPAA Notice of Privacy Practices.

RELEASE OF INFORMATION - I, the below named patient, do hereby authorize any physicians examining and/or treating me to release any third payer (such as an insurance company or governmental agencies, ie Blue Cross Blue Shield of Florida) any medical, psychiatric condition, alcohol or drug related condition and any records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment for such treatment and/or diagnosis.

PHYSICIAN INSURANCE ASSIGNMENT - I, the below named subscriber, hereby authorize payment directly to any physician examining or treating ,e or any group and /or individual surgical and/ or medical benefits herein specified and otherwise payable to me for the services as described but not to exceed the reasonable and customary charge for theses services.

MEDICARE/MEDICAID - Patient's certification authorization to release information and payment request. I certify that the information given by me in applying for my payment under Title XVIII XIX of the Social Security Act is correct. I authorize any holder of medical or other information about meto release to Social Security Administration Division of Family Services or its intermediaries or carries and information needed for this or a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to treatment shall be assigned to the physician treating me.

PERMIT A COPY OF THIS AUTHORIZATION AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL WHICH IS ON FILE AT THE PHYSICIAN'S OFFICE. The assignment will remain in effect until revoked by me in writing.

CONSENT FOR TREATMENT - I, the below named patient hereby give my consent for treatment to all physicians associated with West Orlando Internal Medicine, LLC

CONSENT TO DISCUSS MEDICALCONDITION OR RELEASE RECORDS - I, the below names patient, do hereby authorize West Orlando Medicine, LLC to discuss my medical conditions with, or release my medical records to the below named person (s):