Belvoir Terrace 2023 Summer Camp Pharmacy Form

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INSTRUCTIONS

Please complete the entire form no later than May 31, 2023.
PLEASE NOTE: this process is not complete until we receive your child's prescriptions from your doctor, correct credit information and working prescription insurance coverage.

Make a CLEAR copy of your insurance card (front and back) to send in with your Child's prescriptions.

*Email, Fax or Mail prescriptions and insurance card information to:

Email - summercamps@lviprx.com

Fax (413) 637-4781

Mail: Lenox Village Pharmacy 5 Walker Street, Suite 1 Lenox MA 01240
Attention: Holly Doyle, Certified Pharmacy Technician

Phone (413) 637.4700 x116

My Child will be Attending:*

6 Week Session June 25, 2023 - August 9, 20235 Week Session June 25, 2023 - July 30, 20234 Week Session (for grades 2-5) June 25, 2023 - July 23, 20233 Week Session (doe grades 2-5) June 25, 2023 - July 16, 2023

Camper Information

Gender*

MaleFemaleNon-BinaryUndefined

*This information MUST match the information you provided to your
pharmacy insurance carrier.

Child's Name*

Child's First NameChild's Last Name

Child's Date of Birth*

Date

Child's Social Security #*

Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian's Name*

Parent/Guardian's First NameParent/Guardian's Last Name

Parent/Guardian's Email

example@example.com

Parent/Guardian's Cellphone Number

Please enter a valid phone number.

Prefer to be contacted using

EmailText

Parent/Guardian's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does your child have any allergies?*

YesNo

List of Allergies

MEDICATIONS

Please list ALL of your Child's medications in the area provided below. You will need to specify the medication type (prescription, nutritional or over-the-counter) a manufacturer (for nutritionals only) and provide the medication, strength, form for OTC products (i.e. tablet, capsule, spray, etc.), frequency, (i.e. : "1x daily" or "as needed") and times required for dispensing each medication.

EXAMPLE 1 Prescription Medications

(Medication type) Prescription - (Manufacturer) N/A - (Medication Name) Concerta - (Strength) 36mg tablet - (Frequency) 2x daily - (Dispensed) 8am and 8pm

EXAMPLE 2 Nutritionals

(Medication type) Nutritionals - (Manufacturer) Nordic Naturals - (Medication Name) Ultimate Omega Jr - (Strength) 55mg capsule - (Frequency) 1x daily - (Dispensed) 8am

EXAMPLE 3 Over-the-Counter Medications

(Medication type) Over-the-Counter - (Manufacturer) N/A - (Medication Name) Zyrtec - (Strength) 10mg dissolve tabs - (Frequency) 1x daily - (Dispensed) as necessary

NOTE

Unless otherwise specified, all prescriptions written for once a day will be dispensed at breakfast/morning. Those prescriptions written for twice a day can be dispensed at breakfast/morning and dinner/evening. If other times are required, they must be specified.
Unless the prescription is written "No Substitutions" by law it will be filled with a generic brand.
The following items may be brought to camp (please make sure they are properly labeled):
- Epi-pens (2 pens are required for each at-risk-camper)
- Injectable medications (e.g., allergy shots, hormones, etc.)
- Syringes for injection (please provide adequate supply along with injectable medications)
- Asthma/Respiratory inhalers (2 inhalers are required due to pre-packaging of out-of-camp trips)
- Albuterol (aka, Ventolin, Proventil, AccuNeb, Propair, Vospire) are required personal nebulizer
- Lactaid/Lactase enzyme tablets
- Hydrocortisone cream/ointment/lotion (1.0% or less)
Some Orally Disintegrating Tablets may not be compatible with Auto Med packaging and will be dispensed in their original package.

Enter Medications here:

Only one medication per line

PRESCRIBING PHYSICIAN

Physician's Name*

First NameLast Name

Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physician Phone #*

HOME PHARMACY

Home Pharmacy Name*

Home Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

INSURANCE & SUBSCRIBER INFORMATION

Please be sure to forward a copy of your insurance card front and back, to LVIP.

Pharmacy Insurance Carrier*

Member ID#*

RX Group#*

RXPCN#*

RXBin#*

Subscriber's Name*

Subscriber's First NameSubscriber's Last Name

Patient's Relationship to Subscriber*

RELEASE OF INFORMATION (Title 42 CFR): The Undersigned hereby permits Lenox Village Integrative Pharmacy (LVIP) and its workforce, to disclose the patient's personally identifiable information for purposes related to the patient's treatment to obtain payment for the patient's treatment and in the other circumstances where federal law does not require my further authorirization. The Undersigned also grants permission to release medical information to other health care providers involved in the patient's care and to others involved in planning for the care of the patient. The undersigned likewise grants permission for these parties to release appropriate information back to LVIP, This consent is subject to revocations at any time except to the extent that LVIP has already taken action in reliance on it. If not previously revoked, this consent will terminate six (6) months from last invoice for pharmacy service.

ASSIGNMENT OF BENEFITS: The Undersigned hereby certifies that all insurance information reported to LVIP includes all available sources of coverage, and assigns to LVIP, sufficient monies from said insurance to pay for the patient's precription needs.

FOR PATIENTS ENTITLED TO MEDICARE BENEFITS: If applicable, the Undersigned hereby certifies that the information provided in applying for payment under Title XVIII of the Social Security Act is correct. The Undersigned authorizes LVIP to release to the Social Security Administration and Centers for Medicare and Medicaid Services (CMS) or its intermediaries or carriers, any information needed for this or a related Medicare claim. The Undersigned also requests that payments of authorized benefits are made on the patient's behalf. The Undersigned assigns benefits payable for pharmacy services to LVIP and authorizes LVIP to submit a claim to Medicare for payment.

FOR CO-PAYS, FEES AND ITEMS NOT COVERED BY MY INSURANCE: I authorize the Pharmacy to contact the insurance company to verify insurance coverage for the Child. I acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication the pharmacy cannot get reimbursed for, as well as any co-payments, deductibles, and over-the-counter items I order, which I agree will be billed directly to my credit card by the Pharmacy. I authorize LVIP to charge the credit card indicated in this authorization form, and I certify that I am an authorized user of this credit card.

PLEASE CHECK THE FOLLOWING:

*

I authorize pharmacy to contact the Insurance company for insurance verification.

*

I acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication the pharmacy cannot get reimbursed for, as well as any co-payments and deductibles, which I agree will be billed directly to my credit card by the pharmacy.

Signature Guarantor: I acknowledge that all insurance information I have provided is accurate.*

Clear

PLEASE CONTINUE TO THE PAYMENT FORM BY PRESSING THE CONTINUE BUTTON BELOW.