Common Contracts
1 similar Services Provider Agreement contracts
PHARMACY SERVICES PROVIDER AGREEMENTServices Provider Agreement • September 20th, 2017
I, , authorize Heartland Pharmacy, and any other pharmacies owned by PharmEase, LLC (referred to in this agreement as the “Pharmacy”) to provide medications and associated products and services to the above named Patient. I certify that I have the legal authority to sign this agreement on behalf of said Patient and I understand that by signing this agreement I will become 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.
