Consent Agreement

For Provision Of Pharmacy Management Services

By signing this Agreement, you consent to Mainline Health Systems, Inc. (MHSI) providing pharmacy management services to you as more fully described below.

Pharmacy management services are available to you because you have been diagnosed with chronic conditions that are associated with complex medication regimens.

Pharmacy Management Services include access to a pharmacist and health coach to evaluate and manage medications in relation to a patient’s conditions, provide patient education on medications and chronic conditions, and provide support for any medication related problems that may arise. The service also takes into consideration individual patient and provider preferences to better manage chronic conditions. Your progress will be measured by improvement in lab results that are used to evaluate chronic conditions (such as blood pressure, blood glucose, hemoglobin A1c, etc.). Mainline Health Systems, Inc. will be using your progress to measure the success of this program.

MHSI’s Obligations

When providing Pharmacy Management Services, MHSI must:

  • Explain to you (and your caregiver, if applicable), and offer to you, all Pharmacy Management Services that are applicable to your conditions
  • Provide you a written or electronic copy of your care plan

Patient Acknowledgment and Authorization

By signing this Agreement, you agree to the following:

  • You consent to MHSI providing pharmacy management services to you
  • You authorize electronic communication of your medical information with other treating providers as part of your coordination of your care
  • Monthly phone calls and/or office visits to measure your progress
  • You authorize Mainline Health Systems, Inc. to use lab values, medications, conditions, and patient demographics for the purpose of research

Patient Rights

You have the following rights with respect to Pharmacy Management Services:

  • MHSI will provide you a copy of your care plan
  • You have the right to stop the Pharmacy Management Services at any time by revoking this Agreement effective at the end of the then-current month. You may revoke this agreement verbally or in writing.
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