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Consent to Obtain & Share Patient Medication History

Patient medication history is a list of prescriptions that healthcare providers have prescribed. The history provided to our clinician by patients or their guardians and a variety of sources, including pharmacies and health insurers, contribute to the collection of this history.

The collected information is stored in the practice electronic medical record system and becomes part of the medical record. Medication history is very important in helping providers treat symptoms and/or illness properly and avoid potentially dangerous drug interactions.

It is very important that our provider is aware of all medications that patients are taking. This includes over-the-counter drugs, supplements, and herbal remedies. Some pharmacies do not make prescription history information available, and medication history might not include drugs purchased without using health insurance. Receiving this information directly from patients or the guardians of minor patients helps ensure we have a complete picture of a patient’s medication history.

By signing this consent, I give my permission to allow my healthcare provider to obtain and share my medication history from my pharmacy, my health plans, and my other healthcare providers. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.

For parents or legal guardians of minor patients, by signing this consent form, you give permission for the healthcare provider to obtain and share medication history from the patient’s pharmacy, health plans, and other healthcare providers. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.