Pharmacy Assignment and Medication Pickup Authorization

In order to safeguard your prescriptions, it is necessary for you to provide a list of three people who are authorized to pick up your prescriptions. They must be 18 years or older, and present a picture ID at the time of pick up. We will not release your prescriptions to anyone with whom we do not have written authorization.

In addition, due to the nature of the medicines often prescribe in a Pain Management Clinic, it is necessary for you to choose one pharmacy in Tennessee where your prescriptions will be filled. All medications are to be filled at this Tennessee pharmacy and any prescriptions that are called in by CPM will be phoned in to this pharmacy.
When you call CPM for a prescription refill, the operator will transfer your call to your provider’s voicemail. Please leave your name, date of birth and medications that need to be refilled along with the pharmacy number. If you will not be picking up your prescription, you must leave the name of the person who will be picking up your prescription. (PLEASE NOTE: only the three people listed below will be eligible to pick up your prescriptions, and CPM must know in advance who will be picking up your prescriptions.) If you do not designate someone to pick up your prescription on the voice mail, CPM will assume that you will be picking them up. When calling for a prescription refill, it is our policy that all patients allow two business days to process the refill request.

We appreciate your cooperation in the matter as we strive to provide more excellent care to you.

Consultants in Pain Management

Patient's Name *
Patient's Name
Patient's Date of Birth *
Patient's Date of Birth
I am choosing the following Tennessee pharmacy to fill all medication prescriptions provided by Consultants in Pain Management.
Pharmacy Phone Number *
Pharmacy Phone Number
People authorized to pick up medication
Listed below are the people authorized to pick up prescriptions for me. (Must be 18 years of age.)
Authorized Person #1
Authorized Person #1
Authorized Person #2
Authorized Person #2
Authorized Person #3
Authorized Person #3
e.g. JD for John Doe
Today's Date *
Today's Date