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-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: