Korman Healthcare

Pharmacy Services, Health Information and Payment Agreement


Patient/Resident Name: 

Patient/Resident DOB:    

Patient/Resident SS#:    

Patient/Resident Room Number: 

Patient/Resident Allergies: 


Community Name:

Community Address:

Community Phone Number: 

Community Fax Number:


The terms "Patient/Resident," "Responsible Party," and "I" mean the individual for whom medications or OTCs have been ordered and, if applicable, his or her representative who has a valid Durable Power of Attorney ("POA") granting the authority to enter into this Agreement and take on financial obligations on the Patient/Resident's behalf.  If a POA applies, a copy of the POA must be provided.


Third Party Insurance Information

Patient/Resident is responsible to ensure Pharmacy has a copy of  current insurance card (front  and back) for  billing purposes,  and  will   ensure  Pharmacy  is  notified  in  advance  of  any  change  to  the  insurance  plan  or   carrier. Patient/Resident understands that failure to notify Pharmacy of changes in insurance may result in otherwise avoidable out of pocket costs to Patient/Resident.

Insurance #1  I.D. #: (Prescription Benefits)

Insurance # 1  Group #

Prescription BIN #:   

Insurance # 1  Member Services Phone #:


Insurance #2  I.D. #: (Prescription Benefits)  

Insurance #2  Group #  

Prescription BIN #:  

Insurance #2 Member Services Phone #:


Physician Information

Primary Care Physician 

Physician phone:  Fax:


Payment Terms

In  consideration  for  the  Pharmacy  to  provide  medications  and  supplies  to  Patient/Resident  on  an  open  account, Patient/Resident  does  hereby  unconditionally  guarantee  payment  to  the  Pharmacy  for  all  medications  and  supplies purchased  for  and  supplied  to  the  above-named  Patient/Resident.  Per  Arizona  State  law,  dispensed  medications (including OTC’s) are not returnable. Patient/Resident agrees that all invoices for medications and supplies purchased for and supplied to Patient/Resident  are due and  payable upon receipt.  If an invoice is  not  paid  within 30  days  of  the invoice date, the amounts owed shall become delinquent and a 1.5% finance charge (18% per annum) will be assessed on the delinquent amount.  Patient/Resident is also responsible for attorneys’ fees and court costs incurred in the collection of delinquent amounts.

 

Patient/Resident authorizes the Pharmacy to request on Patient/Resident’s behalf all public and private insurance benefits for products/services  supplied to Patient/Resident by the Pharmacy, and   further authorizes payment for such products/services to be made directly to the Pharmacy.


CHILD  SAFETY  WAIVER:  YOU  AGREE  AND  REQUEST  TO  WAIVE  THE  CHILD-RESISTANT  SAFETY CAP REQUIREMENT FOR ALL NEW PRESCRIPTIONS AND REFILLS. BUBBLE PACK, BINGO CARDS, PARATA  PACKAGED  ITEMS  ARE  NOT  CHILD  SAFE  AND  SHOULD  BE  KEPT  OUT  THE  REACH  OF CHILDREN AT ALL TIMES.


Election for Non-covered Items

Our dedicated staff works diligently to provide services in a timely manner in spite of the often complex issues related to insurance  coverage.   Even  with  our  best  efforts  there  may  be  times  when  your  insurance  will  not  cover  all  charges, resulting in out of pocket costs to you.

 

In order to protect you from incurring charges without your approval: Please select either Option 1 or Option 2 below.

 

I DO NOT authorize Korman Healthcare to dispense over the counter (OTC) and prescription medications and products not reimbursed by my insurance.  I am responsible to coordinate these needs directly.

 

 
I  DO  authorize  Korman  Healthcare  to  dispense  over  the  counter  (OTC)  and  prescription  medications  and products  not  fully  or  partially  reimbursed  by  my  insurance.    I  agree  to  pay  any  copay,  deductible,  or coinsurance amounts owed and to reimburse Korman Healthcare’s charges for these items in accordance with the   terms   of   this   Agreement,   health   plan   rules,   and   the   Korman   Healthcare   3rd     Party   Billing Authorization/Insurance Agreement.

 

I acknowledge that per Arizona law, medications (including OTCs) are NOT returnable. 


A Durable Power of Attorney must accompany this form if not signed by Cardholder.

Please choose Option 1 or Option 2 below:

 

I do authorize Korman Healthcare to process my credit card for all Pharmacy purchases, and mail receipts to:

Responsible Party Name

Relationship to Patient/Resident:  

Responsible Party Address:

Responsible Party Phone Number  

Responsible Party Cell Phone Number  

Credit Card information:

CARD #:   

EXP. DATE:  

 

I (Patient/Resident) DO NOT select Korman Healthcare as my preferred pharmacy and accept no responsibility for charges that I have not explicitly approved in advance.


Text Message Program Opt-In

I authorize Korman Healthcare and our affiliates, partners, and independent contractors to send text messages to the responsible party’s cell phone number for the purposes of treatment, payment, and health care operations. For more information about our text message program, see our attached Notice of Privacy Practices and our terms and conditions at: https://kormanhealthcare.com/privacy-and-security/.


Agreement not valid unless signed 

Patient/Resident/Power of Attorney Name or Patients name if no power of attorney:

 

April 16, 2021

Patient/Resident/Power of Attorney Signature:

Leave this empty:

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Signature Certificate
Document name: Pharmacy Services, Health Information and Payment Agreement
lock iconUnique Document ID: 36074aa88536505372a4026125b9cbbfba605f84
Timestamp Audit
July 24, 2020 5:09 pm EDTPharmacy Services, Health Information and Payment Agreement Uploaded by Mark McKee - mike@lawsonclan.com IP 24.112.194.235
July 24, 2020 8:43 pm EDTMichael Lawson - mike@lawsonclan.com added by Mark McKee - mike@lawsonclan.com as a CC'd Recipient Ip: 24.112.194.235
July 24, 2020 9:06 pm EDTMichael Lawson - mike@lawsonclan.com added by Mark McKee - mike@lawsonclan.com as a CC'd Recipient Ip: 24.112.194.235
July 24, 2020 9:11 pm EDTMichael Lawson - mike@lawsonclan.com added by Mark McKee - mike@lawsonclan.com as a CC'd Recipient Ip: 24.112.194.235