Common Contracts
2 similar Patient-Pharmacy Agreement contracts
PATIENT—PHARMACY AGREEMENTPatient-Pharmacy Agreement • March 21st, 2022
I, , authorize Heartland Pharmacy, and any other pharmacy 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), I certify that I have legal authority to sign this agreement on the Patients’ behalf. I have provided the Community/Organization listed above with the most current and accurate medical records for the Patient (the “Records”) and authorize the Community/Organization to provide the Pharmacy with all Records in its possession or control. I further acknowledge and approve that, when necessary, any information with the possession or control of the Community/ Organization may be relayed to the Pharmacy through any secured means including, but not limited to verbal communications in person or over the phone or via secured email. By my signature, I also permit the Community/Organization to
PATIENT—PHARMACY AGREEMENTPatient-Pharmacy Agreement • December 21st, 2021
Financial Responsible Party (please print) Relation Address Apt/Rm# City State Zip Code Phone Number Email p Online Statement Access Patient Emergency Contact (please print) Phone Number
