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E-Subscribe Consent Form

Please review and complete information below, sign and submit.

Electronic Prescribing (ERX)

  • Allows our doctors to electronically send an accurate, error free and understandable medication prescription directly to the pharmacy;

  • Provides a formulary and benefit list so that your doctor can determine which medications are covered by your insurance drug benefit plan;

  • Provides our doctors with information about your current and past medication history. This allows our providers to be better informed about potential medication issues and to use that information to improve safety and quality;

  • The medication history data can indicate: compliance with prescribed regimens, drug-drug interactions, adverse drug reactions and duplicative therapy.


The medication history information will include medications prescribed by your provider at Eyecare Professionals as well as your other health care providers. This information may also include sensitive information including but not limited to: medications for mental illness, sexually transmitted diseases, contraception, substance (drug and alcohol) abuse, genetic diseases and HIV/AIDS. As part of the Consent Form, you specifically consent to release of this and other sensitive health information.



By signing this consent form, you are agreeing that your provider at Eyecare Professionals may request your prescription medication history from other healthcare providers and/or third-party benefit payors for treatment purposes.


You may decide not to sign this form. Your choice will not affect your ability to receive care and you will not be denied health services.


Understanding all of the above, I hereby provide informed consent to Eyecare Professionals to enroll me in the E-Prescribe program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

Received. Thanks for submitting.

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