Pharmacy Services, Health Information and Payment Agreement
Patient/Resident Room Number:
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 #:
Primary Care Physician
Physician phone: Fax:
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.
Option 1: 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.
Option 2: 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.
Check to acknowledge
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:
Option 1: 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:
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/.
Opt in to text message program? YesNo
Agreement not valid unless signed
Patient/Resident/Power of Attorney Name or Patients name if no power of attorney:
May 20, 2022
Patient/Resident/Power of Attorney Signature:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Pharmacy Services, Health Information and Payment Agreement
Agree & Sign