Healthcare Pharmaself Offer

HEALTHCARE PHARMASELF OFFER

Offer Summary

Offer Reference:    Effective Date:

This Pharmaself Offer ("Offer") describes the terms under which the pharmacy will provide automated dispensing and distribution services for the prescription(s) identified below through unmanned self-dispensing kiosks, mail delivery, or other designated distribution channels. Acceptance of this Offer by signing below constitutes a binding patient authorization and enrollment in the Pharmaself program described herein.

Patient Information

Insurance Information

Prescription & Program Details

Intended Frequency/Schedule:    Estimated Offer Price per Dispense: $

Delivery / Pickup Method (select preferred):
Self-service kiosk pickup Mail delivery Pharmacy counter pickup

Medical History

Program Terms, Consent, and Authorization

By signing this Offer, Patient authorizes the pharmacy to dispense the medication(s) listed above pursuant to this Offer and to bill insurance and/or collect patient responsibility amounts as permitted under applicable law. Patient acknowledges that automated dispensing systems and mail distribution may have operational limits and that availability of specific dispensing methods is subject to pharmacy policies.

Authorization to Obtain and Disclose Protected Health Information: Patient authorizes the pharmacy, its agents, and its service providers to obtain, use, and disclose protected health information as necessary to provide Pharmaself services, to coordinate benefits, to process claims, to notify Patient of refill and delivery information, and to communicate with designated caregivers. This authorization includes prescription records, medication history, insurance claims information, and limited clinical notes relevant to medication management.

Patient Initials to Acknowledge Specific Authorizations:    Initials:    Expiration Date of this Authorization:

Right to Withdraw and Termination: Patient may revoke this authorization in writing at any time, subject to any action already taken in reliance on the authorization. Termination of enrollment in the Pharmaself program does not affect obligations incurred prior to termination, including outstanding balances for dispensed medication.

Risks, Benefits, and Alternatives: Benefits of enrollment may include increased convenience and adherence support. Risks include potential delays in dispensing due to technical failure, misdirected mail delivery, or inventory constraints. Patient has the right to choose alternative methods of medication access including standard pharmacy counter dispensing.

Limitation of Liability and Indemnification: The pharmacy will exercise reasonable care in providing Pharmaself services. To the maximum extent permitted by law, the pharmacy is not liable for incidental or consequential damages arising from use of automated dispensing systems, mail delivery, or third-party carriers. Patient agrees to indemnify and hold the pharmacy harmless for claims arising from Patient's failure to provide accurate information or to follow medication instructions.

Insurance Billing and Payment: The pharmacy may submit claims to Patient's insurer(s) for services provided. Patient is responsible for deductibles, copayments, non-covered charges, and amounts not paid by insurance. If insurance benefits are denied or reduced, Patient remains responsible for payment.

Electronic Communications & Reminders: I consent to receive text message reminders and notifications. I consent to receive automated phone calls regarding my prescriptions.

Caregiver Access: Permit disclosure to designated caregiver

Acknowledgements and Authorizations (checkboxes)

I have read, understand, and agree to the Program Terms, Consent, and Authorization set forth in this Offer. I certify that the information provided in this Offer is true and accurate to the best of my knowledge. I authorize auto-refills for the medication(s) listed, subject to prescription validity and pharmacy policies.

Patient understands that this Offer is an agreement for services and not a guarantee of clinical outcome. Patient may request a copy of this signed Offer for personal records.

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