Pharmacy Agreement for Resident/Responsible Party
(This for MUST be complete prior to filling medications)
Name of Resident
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Name of Person to be billed (POA)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Social Security Number
*
Medicare Number (MBI)
Insurance/Payment Information
**Please provide a copy of both sides of insurance cards**
File Upload (Insurance and Medicare card upload) *Please provide front and back*
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of
Insurance Carrier
BIN #
PCN #
ID #
Group #
If Patient is Tricare, Please provide the sponsors full social security number.
Sponsor Social Security Number
I understand that certain insurance claims may be filed as a courtesy. However, if for any reason the claim in denied I am responsible for payment. I understand it is my responsibility to pay any deductible amount, co-insurance or any other balance not paid for by my insurance or third party payer.
I agree to pay for all medications and supplies ordered for the above resident by their health care provider. All medications or co-pays that are not covered by third party payers, these charges would then be considered private pay charges.
Resident or Responsible Party/Guarantor Signature
*
Date Signed
-
Month
-
Day
Year
Date
Account Payment
A credit card is required for co-pays, over the counter medications and supplies. This card will be billed on a monthly basis for outstanding charges. **Please Call 321-452-0010 ext #3 to give your credit card information over the phone for security purposes**
Signature
*
Date
-
Month
-
Day
Year
Date
Thank you for choosing Hobbs Pharmacy!
If you have any questions, at any time, please do not hesitate to call us at 321-452-0010 "Improving Healthcare in Brevard County Since 1964"
Hobbs Pharmacy
133 N. Banana River Drive. Merritt Island, Florida 32952 (321)452-0010 Fax (321) 576-0529 Hobbspharmacy@hobbsrx.com
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