Healthcare Pharmazy Agreement

HEALTHCARE PHARMAZY AGREEMENT

Patient Information

Insurance / Payment Information

I authorize the Pharmacy identified below to bill my insurance and to collect payment from me for medications and pharmacy services not covered by insurance. I understand that I remain financially responsible for all charges not paid by my insurer and for any copayments, coinsurance, or deductibles.

Pharmacy / Service Provider

Pharmacy Representative:   Phone:

Medical History

Authorization and Consent

I, the undersigned patient, hereby authorize the Pharmacy named above to provide pharmacy services on my behalf, including dispensing and administering prescribed medications, coordinating medication management with my prescribers, performing medication reconciliation, and communicating medication-related information to my healthcare providers and insurer as necessary to facilitate treatment and payment.

I authorize my healthcare providers, clinics, hospitals, and insurers to release to the Pharmacy my protected health information (PHI) as necessary to fulfill prescriptions, process claims, and provide care coordination. PHI disclosed may include diagnosis, medication history, lab values relevant to medication therapy, and insurance coverage details.

Purpose of Disclosure: treatment, payment, healthcare operations, prior authorization and care coordination. This authorization permits the Pharmacy to receive and use my PHI for those purposes and to disclose PHI to other providers and payors only as required for those purposes.

Limitations, Risks, and Patient Responsibilities

The Pharmacy will exercise reasonable skill and care in providing services, but cannot guarantee outcomes. I understand risks associated with medications may include adverse reactions, interactions, or lack of efficacy. The Pharmacy will counsel on significant risks when identified. I agree to provide accurate medication and allergy information and to notify the Pharmacy of changes in health status, pregnancy, or lactation.

Assignment of Benefits and Financial Authorization

By signing this Agreement I authorize assignment of my insurance benefits to the Pharmacy to the extent permitted by my insurer. I authorize my insurer to remit payment directly to the Pharmacy for covered services. I agree to pay any non-covered charges, copayments, coinsurance, and deductibles.

Privacy / HIPAA Acknowledgment

I acknowledge receipt of the Pharmacy's privacy practices describing how my health information may be used and disclosed and my rights with respect to that information. I understand that the Pharmacy may use and disclose my PHI for treatment, payment, and healthcare operations, and as otherwise permitted or required by law.

Term, Revocation, and Expiration

This authorization is effective upon my signature below and will remain in effect until revoked in writing by me, or until the date specified below, whichever occurs first. Revocation will not affect disclosures previously made in reliance on this authorization while it was in effect.

Expiration Date:

Representations, Indemnity, and Governing Law

I represent that the information provided in this Agreement is true and complete to the best of my knowledge. I agree to indemnify and hold the Pharmacy and its agents harmless from any claims, liabilities, losses or expenses arising from my failure to provide accurate information or from my misuse of medications provided under this Agreement, except to the extent caused by the Pharmacy's gross negligence or willful misconduct.

This Agreement shall be governed by the laws of the state in which the Pharmacy maintains its principal place of business, without regard to conflict of laws principles.

Acknowledgment and Signature

By signing below I acknowledge that I have read and understand this Healthcare Pharmazy Agreement, that I have had the opportunity to ask questions, and that I consent to the uses and disclosures of my protected health information as described herein.

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