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 Agreement FormPatient/Pharmacy Agreement • May 5th, 2010
Drink the methadone in front of the pharmacist/suitably trained pharmacy technician (or if taking buprenorphine, allow the tablet to dissolve under the tongue)
if applicable)Patient-Pharmacy Agreement • July 12th, 2021
Apt/Rm# Home Phone PLEASEHome Address Date of Birth p M p F ATTACHCOPIES OFCity State Zip Code SSN FRONT ANDBACK OFPhone Medicare # PATIENT’SPhysician(s) Medicaid # INSURANCECARDSPrescription Insurance ID# REMINDER: MostOTC items are notRX Group# RX PCN# RX BIN# covered by insurance.Drug/Food Allergies p No Known AllergiesReactions Medical Ins.# (for DME/Vaccinations) Should you need more space, please attach additional documentation. 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 signin
