e-Prescribing Consent (PBM) CONSENT FOR e-PRESCRIBING ENROLLMENT(Required) I give informed consent to John R. Porter, MD, PA to enroll me in the ePrescribe program. I have had an opportunity to ask questions and all my questions have been answered to my satisfaction.John R. Porter, MD, PA uses an electronic medical record system that allows ePrescribing of medications. ePrescribing is defined as a physician's ability to electronically send accurate, error free, and understandable prescriptions directly to a pharmacy from the point of care, through a secure connection (Surescripts), greatly reducing medication errors and enhancing patient safety. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. The Medicare Modernization Act (MMA) of 2003 listed standards that must be included in an ePrescribing program. These include: *Formulary and Benefit Transactions: Gives the prescriber information about which drugs are covered by the drug benefit plan. *Medication History Transaction: Provides the physician with information about previous and current medications that the patient is taking to minimize the number of adverse drug reactions. *Fill Status Notification: Allows the prescriber to receive an electronic notice from the pharmacy telling g them if the patient's prescription has been picked up or partially filled. By signing this consent form, you are agreeing that John R. Porter, MD, PA may request and use your prescription medication history from other healthcare providers and/or third-party pharmacy benefit payers for treatment purposes. Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Signature of Parent/Guardian(Required) Today's Date(Required) MM slash DD slash YYYY Relationship to Patient