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Patient Forms

Patient Forms

When it comes to your health information, you have certain rights. This section explains your rights and provides the forms necessary to carry out your most common requests. You can download a copy of each form by clicking on its name in the list below.

You can send completed forms to us via:

Email:
privacy@exactcarepharmacy.com

Fax:
216-369-2201, Attention: Compliance

Mail:
ExactCare Pharmacy
Attention: Compliance
8333 Rockside Rd
Valley View, OH 44125

Request to Access Records

Use the Request to Access Patient Records form to request copies of your pharmacy records.

You may request a copy of any personal information that ExactCare maintains, such as billing or medication records. You can also ask that we send a copy of your records to another person or organization, such as another healthcare provider. This must be made in writing, identifying the person or place to send the records, and signed by the patient.

Request to Share PHI with a Contact

If you have given someone medical power of attorney or if someone is your legal guardian, send us a copy of the official documentation via email, fax, or mail.

If you do not have a power of attorney, you can still give us permission to share and discuss your PHI with anyone you choose. Does your spouse or child handle your medications? Would you like your neighbor to be able to call us on your behalf to discuss personal information? Use the Request to Designate a Personal Representative to Have Access to PHI to provide information for the designated individual(s) and sign off on the authorization. We will keep this on file for as long as you wish the person(s) to have access to your PHI.

Request to Waive Signature Requirement

Some medications require that we obtain your signature at the time of delivery. Sometimes, this is not always possible for you and you miss your medications due to reasons like, you are not home at the usual delivery times, you are unable to get to the door quickly enough, etc.

If you would like to waive this requirement for any reason, use the Request to Waive Signature Requirement for Medication Deliveries form to request that no signature is required upon delivery of your medications.

Request for Confidential Communications

You may request to receive confidential communications of Protected Health Information (PHI) by alternative means or at alternative addresses. Use the Request for Confidential Communications via Alternate Means form to request that we communicate with you by an alternative address or phone number. For example, you wish to be called on your cell phone instead of your home phone, or would like billing correspondences sent to your power of attorney’s address rather than your home address.

Request for Amendment to PHI

If you see something in your MyECP portal or patient records that you think is incorrect or incomplete, you can ask us to correct it by using the Request for Amendment to PHI form. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Contact us for other forms you may need to:

  • Ask us to limit the information we share [This form will help patients who wish to restrict certain uses and disclosures of their PHI.]
  • Get a list of those with whom we’ve shared your information [For patients who would like a record of all disclosures of their protected health information.]
  • Get a copy of the ExactCare privacy notice [This notice informs you of our privacy practices at ExactCare.]
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1-877-355-7225