Patient Information Release Consent Form
This document is a consent form for releasing a patient’s contact lens prescription from Dr. Robert D. Forbes & Associates to 1-800-CONTACTS. It includes patient information fields, clinician details, and important legal warnings. Users must complete the form and return it via fax to facilitate the prescription transfer.
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How do I fill this out?
To fill out the form, start by providing the patient's last name, date of birth, and social security number. Next, the patient must authorize the release of their prescription information by signing the form. Finally, fax the completed form to the office of Dr. Robert D. Forbes & Associates.
How to fill out the Patient Information Release Consent Form?
1
Begin by entering the patient’s last name.
2
Fill in the patient’s date of birth and social security number.
3
Authorize the release of the prescription by signing the form.
4
Fax the completed form to Dr. Robert D. Forbes & Associates.
5
Contact the office for confirmation if necessary.
Who needs the Patient Information Release Consent Form?
1
Patients who need their contact lens prescription sent to 1-800-CONTACTS.
2
Clinics that require patient authorization to release prescription information.
3
Patients switching to 1-800-CONTACTS for purchasing contact lenses.
4
Healthcare providers managing patient prescriptions.
5
Patients needing a valid prescription for legal and medical compliance.
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1
Upload the PDF to PrintFriendly.
2
Click on the text fields to enter the necessary details.
3
Edit any information directly on the form.
4
Save the changes once you have completed editing.
5
Fax the edited form to the specified fax number.
What are the instructions for submitting this form?
To submit this form, complete the patient information fields, sign the form, and fax it to Dr. Robert D. Forbes & Associates at (503) 652-1690. You can also contact their office at (503) 652-1479 for additional information. Make sure all details are accurate to avoid delays or compliance issues. It is recommended to keep a copy of the form for your records.
What are the important dates for this form in 2024 and 2025?
There are no specific dates associated with this form. It can be used whenever a patient needs their contact lens prescription transferred.
What is the purpose of this form?
The purpose of this form is to facilitate the legal transfer of a patient’s contact lens prescription from Dr. Robert D. Forbes & Associates to 1-800-CONTACTS. By completing and signing this consent form, patients authorize the clinic to release their prescription information to the contact lens supplier. This ensures compliance with both Oregon State Law and Federal Law, which require a signed prescription for dispensing contact lenses.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Last Name: The last name of the patient requesting their prescription to be transferred.
- 2. Date of Birth: The birthdate of the patient for identification purposes.
- 3. Social Security Number: The social security number of the patient to further verify their identity.
- 4. Signature: The patient’s or guardian’s signature authorizing the release of prescription information.
What happens if I fail to submit this form?
Failure to submit this form correctly will result in the inability to transfer the contact lens prescription. This may cause delays or prevent the patient from obtaining their contact lenses.
- Invalid Prescription Transfer: Without submission, the prescription cannot be legally transferred to 1-800-CONTACTS.
- Delay in Obtaining Lenses: Patients may experience delays in receiving their contact lenses without a valid prescription on file.
- Legal Compliance Issues: Failure to submit the form correctly may result in non-compliance with state and federal laws regarding prescription transfers.
How do I know when to use this form?
- 1. Prescription Transfer: When a patient needs their contact lens prescription sent to 1-800-CONTACTS.
- 2. Authorization of Release: When granting authorization for the clinic to release your prescription information.
- 3. Legal Compliance: To ensure compliance with laws regulating the dispensing of contact lenses.
Frequently Asked Question
How do I fill out the contact lens prescription form?
Use the PrintFriendly PDF editor to input the necessary patient details, sign the form, and save it before submitting it via fax.
Can I edit the PDF form online?
Yes, with PrintFriendly, you can edit the PDF form online by entering details directly into the fields provided.
How do I sign the PDF form?
You can sign the PDF form using PrintFriendly’s digital signature feature by drawing your signature directly on the document.
Is it possible to share the completed form?
Yes, you can share the completed form using PrintFriendly's sharing options, including email or direct link.
Where do I submit the completed form?
You can fax the completed form to the specified fax number provided by Dr. Robert D. Forbes & Associates.
Can I save the edited PDF?
Yes, after editing the PDF on PrintFriendly, you can save the file and store it on your device.
What information do I need to fill out the form?
You need the patient’s last name, date of birth, social security number, and signature.
Can I contact the clinic for more information?
Yes, you can reach out to Dr. Robert D. Forbes & Associates using the contact details provided in the form.
Why do I need to fill out this form?
This form is required to legally release the patient’s contact lens prescription to 1-800-CONTACTS.
What happens if the form is not filled out correctly?
If the form is not correctly filled out, the prescription cannot be legally released, and you may face delays in obtaining contact lenses.
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