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Protecting Hoosiers One Prescription At A Time
I (the Dispenser/Practitioner) attest that I am not submitting a change order request under false pretense in an effort to alter or fabricate patient information. I understand that all valid or invalid data modifications are solely my responsibility as the dispenser/practitioner.
I understand that INSPECT is under no obligation to investigate the validity of my Pharmacy Change Order Request and Digital Signature (Notwithstanding my pharmacy NABP number, professional license number, DEA number, my date of birth and name). I am duty-bound to abide by all applicable Federal and State guidelines including, but not limited to, IC-35-48-7 and The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Misuse of INSPECT's data constitutes a criminal offense and may result in the suspension/revocation of access privileges, or, in some cases, action against offending accountholder's and/or agent's professional license.
I acknowledge/agree to the Electronic Signature Agreement
PRESCRIPTION SPECIFIC INFO:
In order to modify existing records within the prescription management program system, you, or your authorized reprensentive, will be required to use an electronic signature. Please be aware that an electronic signature is as legally binding as a handwritten signature. Click here to read the full Electronic Signature Agreement www.in.gov/inspect
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