PA Attestation Form


Prior Authorization Consent Attestation

For Pharmaceutical Prior Authorization Processing

Name of Practice

Practice Address

NPI#

Other Consenting Practice Physicians:

Name: NPI:

Name: NPI:

Name: NPI:

Name: NPI:

Date

 

I, , acknowledge that: I have provided the notice of privacy practices to and obtained consent from my practice’s patients (or their authorized representatives) in accordance to the Health Insurance Portability and Accountability Act as required by applicable state law and/or regulations. I hereby provide consent to Rite Care Pharmacy to facilitate the processing of my patient’s pharmaceutical prior authorizations as needed. Rite Care Pharmacy is a covered entity and will also comply to all Personal Health Information confidentiality requirements in accordance to the Health Insurance Portability and Accountability Act as required by applicable state & federal laws and regulations. If signing for all physicians in a practice: This confirms that I am authorized to act on behalf of the members of the physician practice group named above. In that capacity, I will assure that they have provided the notice of privacy practices to and obtained consent from their patients (or their authorized representatives) concerning personal health information in accordance to the Health Insurance Portability and Accountability Act as required by applicable state and federal laws and regulations. They will review a copy of this document, and understand and comply with the informed consent requirements described above. This attestation remains in effect until an updated form is submitted.

Signature of medical practitioner:

OR:

Signature of medical practitioner authorized

to act on behalf of the physician practice group:

 

NPI

Leave this empty:

Rite Care Pharmacy https://www.ritecarerx.com
Signature Certificate
Document name: PA Attestation Form
Unique Document ID: 1b5f80f331d2dc50ae3afa10114ab3dfab78d5c5
Timestamp Audit
2017-02-15 00:11:24 EDTPA Attestation Form Uploaded by Rite Care Pharmacy - rcpromise@ritecarerx.com IP 50.84.74.34