Conway's Pharmacy/Kenyon Student Agreement

Kenyon College Health Center New Student Information & Delivery Agreement

1451 Yauger Road Suite 1H Mount Vernon, OH 43050 Phone - 740-397-1420 Fax - 740-397-2454 Email - rx@eastsidepharm.com Website - www.conwayspharmacyoh.com
PLEASE SEND INSURANCE INFO WITH THIS FORM
Name*
D.O.B.*
Kenyon PO Box
Gender

FemaleMaleOther
Student Mobile Number *
This will be the Primary contact number while at Kenyon College.
Do you want to be enrolled in our auto-refill problem( only for non-controlled medications)?*
It is the responsibility of the patient to let pharmacy know is the auto refill program needs turned off or if a medication gets discontinued. Medication CAN NOT be returned once it leaves the pharmacy.
Student E Mail*
example@example.com
Medication Allergies*
Home Address and Zip Code*
Parent Phone Number*
We do need one backup phone number on file as emergency contact.
Respect for your privacy is a top priority at Conway's Eastside Pharmacy (CEP). Conway's Eastside Pharmacy practices in compliance with federal regulations that are part of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), which addresses your rights to privacy and handling of Protected Health Information ("PHI" We have patients request that we leave detailed voice messages about their prescription or we have patients notify us that a friend or family member will be picking-up their prescription. While we try to accommodate our customers, we also must adhere to HIPAA regulations. The form below will allow us to leave voice messages at specific telephone numbers, authorize prescription pick-up contacts, and release information about you, the patient, to those authorized by you. (This is required for those patients 18 and older.)
Can Conway's Pharmacy leave a basic and/or detailed voice message at the numbers provided below?*

Student MobileParents NumberOther
These individual(s) have been selected by the patient listed above as an authorized contact for the specified information.*
Academic Year -
Information to Be Released to Contacts: Patients, 18 and older, are to select information and/or items that the above individual(s) listed can receive and are authorized to know. Please initial in the boxes below for the items or information that can be released to the above individual(s).
Medical Information (Any information regarding your health diagnosis and treatment plans, etc.)*
Financial Information (Any information regarding your insurance, payment plans, credit & balances, etc.)*
Documentation Pick Up (All individuals who are picking up any documentation must show a form of identification.)*
Prescription Pick Up (All individuals who are picking up prescriptions must show a form of identification.)*
Authorization to request fill/refill of prescriptions on students behalf.*
Patient Signature

Clear
Date

MonthDayYear
PLEASE NO LYING OR FAKE SIGNATURE FOR THE PATIENT ON THE ABOVE LISTED SIGNATURE!
Authorizing Patient Information NOT to be Released - (for patients 18 years and older)

By signing this section below, you are choosing NOT to release ANY of the above information to ANY individual(s) other than yourself. This means that spouses, children, family members, etc. cannot pick-up prescription(s) or access any information regarding your prescription(s) filled at CEP.
Patient Signature

Clear
Date

MonthDayYear
Date
I understand and agree to cover all prescription cost/copays and delivery charges ($6.00) with the form of payment provided below. I understand CEP will charge my credit card for the above referenced charges. In the event my form of payment does not allow approval of charge, CEP has the right to cancel/hold delivery of my medication and attempt to notify me of such cancellation. If no approval is made by 3pm Monday-Friday my medication will not be delivered that same day.*

YesNo
I agree to have Conway's Eastside Pharmacy (CEP) fill and arrange for delivery of my prescriptions to my Kenyon College PO box or the Gund Common Mail room. The same day delivery cut off time is 2pm.*

YesNo
I understand that CEP WILL NOT exchange medication or return any monies paid once on any order that was shipped. This is pursuant to State pharmacy law OAC 4729-9-04. I understand I must check my designated PO box before the end of academic year and academic breaks and that CEP cannot return any medications if not picked up or return any payments for medications not picked up.*

YesNo
CREDIT CARD AUTHORIZATION
PLease reach to us with your payment information as we can not collect this information on this form. If we do not hear from you, we will reach out to you to collect your payment information before we are able to deliver your medications.

Thank you.

Conway's Pharmacy Management
I authorize Conway's Pharmacy to charge my credit card for prescription and delivery charges. I understand and agree that I am responsible for all the charges incurred for prescription and delivery services from CEP. *

Clear
CONFIDENTIALITY AND NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

I acknowledge that I have been given the opportunity to read the Notice of Privacy Practices (NOPP) of Conway's Eastside Pharmacy, posted in the pharmacy or have been given my own copy. I acknowledge that I agree with the patient authorization information provided above.

I understand that Conway's Eastside Pharmacy, through its HIPAA policies is obligated to protect my confidental personal health information. I have the right to request to see their HIPAA policies at any time. Conway's Eastside Pharmacy reserves the right to change the terms of its Privacy Notice. If such changes are made, I understand that the Privacy Notice will be posted on the CEP website and I can request a copy at any time.

I understand that I am responsible to provide current and accurate insurance information to Conway's Eastside Pharmacy and a copy of their current insurance card. I also understand that a delay in getting current and accurate insurance information to the pharmacy will result in a delay in getting my prescriptions. I understand that I may also get an option to pay out-of-pocket for prescription(s) if I cannot obtain current and accurate insurance informationin a timely manner.

I verify by my signature below that I give permission for prescription(s), over-the-counter item(s) and delivery services; I have been informed of my privacy rights; I am responsible for charges on my credit card and authorize of my health informtion to process any insurance claims.
Signature of patient*

Clear
Date*

MonthDayYear
Date
PLEASE UPLOAD IMAGE OF INSURANCE CARD FRONT AND BACK BELOW.
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Kenyon College Health Center New Student Information & Delivery Agreement

PLEASE SEND INSURANCE INFO WITH THIS FORM

CREDIT CARD AUTHORIZATION