CPRX Resident Agreement Form

Resident Intake and Agreement Form
Patient's Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
SSN
Phone Number
Please enter a valid phone number.
Address

Street Address

Apt./Unit#

CityState / Province

Postal / Zip Code
Allergies to Medications
Resident Community

PCP Information
PCP Name
PCP City & State
PCP Phone Number
Please enter a valid phone number.
PCP FaxNumber
Please enter a valid Fax number.
Other Health Care Providers' Information

Please mention specialist's information below if there are any.
Physician 1 Name
Physician 1 City & State
Physician 1 Speciality
Physician 1 Phone Number
Please enter a valid phone number.
Physician 1 Fax Number
Please enter a valid Fax number.
Physician 2 Name
Physician 2 City & State
Physician 2 Speciality
Physician 2 Phone Number
Please enter a valid phone number.
Physician 2 Fax Number
Please enter a valid Fax number.

Billing Contact
Name
Relation
Phone Number
Please enter a valid phone number.
Email
example@example.com
Health Care Contact
Name
Relation
Phone Number
Please enter a valid phone number.
Email
example@example.com

Monthly Billing Statement Application

RESPONSIBLE PARTY INFORMATION
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Options

Manual PaymentAutopay via Electronic Transfer or Credit Card
Payment Type

American ExpressDiscoverMaster CardVisaElectronic Funds Transfer

Agreement for Services

By signing below, the Patient or their Responsible Party acknowledges and agrees to each of the following terms:

1. Authorizations: The Patient or responsible party authorizes enrollment in the Chesapeake Regional Pharmacy LLC medication management program. The Patient requests that the products provided by Chesapeake Regional Pharmacy be dispensed in containers that are not child-resistant. The patient or responsible party agrees that any medication that has been discontinued or expired will be destroyed by the Facility and/or Pharmacy.

2. Notice of Privacy Practices: The Patient or their Responsible Party acknowledges that they have reviewed Chesapeake Regional Pharmacy's Notice of Privacy Practices, which is available at www.crprx.com. The Patient or their Responsible Party may at any time contact Chesapeake Regional Pharmacy directly to request a copy for their records.

3. Assignment of Benefits: The Patient or their Responsible Party hereby requests and authorizes any third-party payer to make payment directly to Chesapeake Regional Pharmacy for products and services provided to the Patient.

4. Billing: The Resident or their Responsible Party acknowledges that Chesapeake Regional Pharmacy will bill the Resident or their Responsible Party directly for the provision of all products and services monthly. The patient/Responsible party agrees that community personnel are authorized to order, purchase, and charge on behalf of the above Resident. Charges from Chesapeake Regional Pharmacy are not part of any billing received from the facility in which they reside.

5. Payment: The Resident or their Responsible Party is responsible for paying all charges for products and services provided to the Resident by Chesapeake Regional Pharmacy. Chesapeake Regional Pharmacy will submit claims on behalf of the Resident to all insurance companies or other third-party payers we have signed contractual obligations, however, the Resident and the Responsible Party are ultimately responsible for paying any charges not covered by insurance or another third-party payer. Payment in full is due within thirty (30) days of the statement date. The Resident or Responsible Party hereby authorizes Chesapeake Regional Pharmacy to charge any credit card or bank account number identified above for any amounts owed.

6. Fees and Expenses: The Resident and their Responsible Party agree to pay all costs of collection, including court costs and attorney’s fees, if necessary, in order for the pharmacy to collect any and all delinquent balances.

7. Assurance of Payment and Termination of Services: The Resident or Responsible Party acknowledges that if the Resident and Responsible Party are delinquent on payment of any amount owed to Chesapeake Regional Pharmacy, Chesapeake Regional Pharmacy may, in its sole discretion, do either or both of the following:

a. Condition its continued provision of products and services to the Resident upon Chesapeake Regional Pharmacy’s receipt of assurance of payment acceptable to Chesapeake Regional Pharmacy, which may include, without limitation, a requirement that Chesapeake Regional Pharmacy receive authorization to charge all amount owed, past and future, to a valid credit card number; and/or

b. Suspend or terminate its provision of products and services to the Resident. Such suspension or termination will in no way affect the Resident’s or Responsible Party’s obligation to pay all amounts owed under this agreement, including costs of collection.

8. Change of Custody: The Patient or Responsible Party acknowledge that once custody of products provided by Chesapeake Regional Pharmacy has beentransferred over to the Patient, either directly or through an intermediary such as a caretaker and/or family member, Chesapeake Regional Pharmacy can nolonger provide any credits or refunds due to federal and state regulations. Change of custody occurs at the point when products provided by Chesapeake Regional Pharmacy are received by, or on behalf of, the Patient, are no longer in control of an employee of Chesapeake Regional Pharmacy, and a signed document of receipt has been completed.

9. Change of Information: The Resident or responsible party agrees to notify the pharmacy of any future changes in address, email address ,or credit card/bank account information
Signature*

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Resident Intake and Agreement Form

PCP Information

Other Health Care Providers' Information

Billing Contact

Health Care Contact

Monthly Billing Statement Application