Common Contracts
4 similar Services Provider Agreement contracts
PHARMACY SERVICES PROVIDER AGREEMENTServices Provider Agreement • May 12th, 2020
Consent to Provide Services and Medical Records PLEASEATTACHI, , authorize Heartland Pharmacy, and any other pharmacy owned by PharmEase, COPIES OFLLC (referred to this agreement as the “Pharmacy”) to provide medications and associated products and services to the above named Patient. If signing FRONT AND this Agreement as an agent of the Patient pursuant to a Power of Attorney (POA). I certify that I have the legal authority to sign this agreement. I certify BACK OF that the Facility/Organization listed above has in their possession and may provide the pharmacy with the most current and accurate medical records for PATIENT’S the above listed patient. I also permit for the above facility to notify the pharmacy of any medical changes and records to the above patient. INSURANCECARDSAssignment of Benefits and Privacy Practices REMINDER: MostI hereby request that payment of authorized insurance benefits be made on the Patient’s or my behalf to the Pharmacy for medications, products and/or
PHARMACY SERVICES PROVIDER AGREEMENTServices Provider Agreement • May 12th, 2020
Apt/Rm# Home Phone PLEASEHome Address Date of Birth 🞐 M 🞐 F ATTACHCOPIES OFCity State Zip Code SSN FRONT ANDBACK OFPhysician(s) Phone PATIENT’S VA Benefits 🞐 Yes 🞐 No INSURANCECARDSMedical Insurance ID# REMINDER: MostOTC items are notPrescription Insurance ID# covered by insurance. RX Group# RX PCN# RX BIN# Drug/Food Allergies 🞐 No Known AllergiesReactions Release of PHIAs outlined in the Pharmacy “Notice of Privacy Practices”, we may disclose your protected health information (PHI) to individuals or entities involved in your healthcare. Provide the names and telephone number of individuals who we may discuss your PHI.Name Phone Name Phone Assignment of Benefits and Privacy PracticesI, , authorize Heartland Pharmacy, and any other pharmacies owned by PharmEase, LLC (referred to this agreement as the “Pharmacy”) to provide medications and associated products and services to the above named Patient. If signing this Agreement as an agent of the Patient pursuant to a Power of Attorney (POA
PHARMACY SERVICES PROVIDER AGREEMENTServices Provider Agreement • May 12th, 2020
Consent to Provide Services and Medical Records PLEASEATTACHI, , authorize Heartland Pharmacy, and any other pharmacy owned by PharmEase, COPIES OFLLC (referred to this agreement as the “Pharmacy”) to provide medications and associated products and services to the above named Patient. If signing FRONT AND this Agreement as an agent of the Patient pursuant to a Power of Attorney (POA). I certify that I have the legal authority to sign this agreement. I certify BACK OF that the Facility/Organization listed above has in their possession and may provide the pharmacy with the most current and accurate medical records for PATIENT’S the above listed patient. I also permit for the above facility to notify the pharmacy of any medical changes and records to the above patient. INSURANCECARDSAssignment of Benefits and Privacy Practices REMINDER: MostI hereby request that payment of authorized insurance benefits be made on the Patient’s or my behalf to the Pharmacy for medications, products and/or
PHARMACY SERVICES PROVIDER AGREEMENTServices Provider Agreement • May 12th, 2020
By signature below, I acknowledge the Patient, or whomever is named as the “Financial Responsible Party” above, will be responsible to pay the usual and customary fee for all medications, products and services provided to the Patient by the Pharmacy at the direction of the facility administration and staff and attending physician(s). If I disagree with any medication, product or service directed by the facility or an attending physician, I will contact them and resolve the issue(s) and ask them to provide different written direction to the Pharmacy. I acknowledge and agree that the Pharmacy provides medications, products or services based upon the most current written direction received by it.
