Erectile Dysfunction Fact Sheet

https://www.cdc.gov/diabetes/library/features/diabetes-and-men.html

Consent for Services

Before providing your consent, be sure that you understand both the pros and cons of receiving treatment from a pharmacy provider. If you have any questions, we will be happy to discuss them with you. Do not sign your name on this form until you have read and understood each statement and the pharmacist has answered any questions that you may have. This information is confidential.

• I understand the benefits and risks of receiving treatment.
• I have voluntarily chosen to receive care service by a pharmacy provider.
• I understand that Pharmacists can assess and treat some authorized conditions, and administer certain services including diagnostic testing, and vaccinations.
• I voluntarily assume full responsibility for any reactions or consequences that may result.
• In the event of side effects, I understand I should call the pharmacy, my doctor, or 911.
• I have had the opportunity to ask any questions I might have about the care and services provided to me by a pharmacy provider and the alternatives prior to my informed consent.
• I give consent to receive care services by the pharmacy provider, including any medications recommended or prescribed, or instructions from the pharmacy provider.
• I understand if the pharmacy provider cannot provide effective care, I may be referred to an appropriate care provider.
• I have read or have had read to me all of the above statements and understand them.

Authorization to Request Treatment

I am requesting participation in receiving treatment for the pharmacist prescribed Erectile Dysfunction program. I certify that the information provided regarding eligibility for the treatment is accurate and request that the treatment be given to me or to the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so.

I authorize the pharmacy providing services to release information to Medicare, Medicaid or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf to the pharmacy providing services, I certify that the information provided about my Medicare, Medicaid or other coverage is correct.

Acceptance of Financial Responsibility

Notwithstanding anything previously set forth, I agree that I am responsible for and will promptly pay on demand any and all obligations to the pharmacy providing services including all self-pay balances as well as those charges for services not covered or disallowed by my insurance carrier.

Disclosure of Records

I understand that the pharmacy providing services may be required to or may voluntarily disclose my health information with respect to this treatment to my healthcare providers, my insurance plan, health systems and hospitals, and/or state or federal registries. I understand that the pharmacy providing services will use and disclose my health information as set forth in the pharmacy privacy policy (a copy is available by request from the pharmacy team).

Before collecting any more health information, we want to emphasize that not all of our patients will be eligible for a prescription for erectile dysfunction, but all patients will still be responsible for paying any applicable consultation fee.

Many men over the age of 18 who are symptomatic can be seen through Scripted for treatment of ED.

Patient may be eligible if:

• Men
• Older than 18 years old
• Erectile Dysfunction Symptoms

Patient may not be eligible if:

• Diagnosed with high-risk heart disease or heart failure
• Experience angina
• Heart attack in the past
• Unable to exercise
• High blood pressure that is not well controlled by diet or medications
• Abnormal heart rate

if you choose to continue you will be asked to complete a self-assessment with questions that will be reviewed with you by a pharmacist during your consultation at the pharmacy. The pharmacist will refer to your responses to help make a safe, informed decision about appropriate care.

• There is a $0 fee for the pharmacist consultation for this service that is separate from the cost of the medication.

• A patient is responsible for paying the fee when they come in for a visit, before the consultation with a pharmacist.

• This fee is applicable even if it is determined by a pharmacist that a patient is not eligible for a prescription and/or needs to be referred to appropriate care.

• The Scripted consultation fee is not covered by insurance at this time.
  • A patient can use insurance to pay for any prescription or medication that results from an assessment.