I hereby authorize the pharmacist/pharmacy technician to contact other pharmacies on my behalf to obtain information regarding my private insurance coverage for the purpose of processing my prescriptions and ensuring the continuity of my care.

I understand that this may include, but is not limited to, retrieving details about my prescription drug coverage, co-payments, deductible amounts, and eligibility for benefits. I acknowledge that this information will be used solely for the purpose of assisting with my medication needs and will be handled in accordance with applicable privacy laws and regulations.

I further understand that:

1. This authorization is voluntary, and I may revoke it at any time by providing written notice.
2. Revocation of this consent will not affect any disclosures made prior to the receipt of the revocation.
3. Information obtained will remain confidential and will not be shared with any unauthorized parties.
4. This consent remains valid until [specify duration, e.g., one year from the date signed] unless revoked earlier in writing.

By signing below, I confirm that I have read and understand this authorization and consent to the retrieval of my insurance information by pharmacies.