I, __________________[Resident's Full Name], hereby authorize Daly Drug LTC Pharmacy, as directed by _____________{Facility Name}, to fill prescriptions ordered by my practitioner or caregiver. I understand and acknowledge that I will be responsible for payment regardless of whether my insurance covers the medication or not.
I acknowledge that it is my responsibility to provide accurate insurance information to the pharmacy. I understand that any inaccuracies or omissions in providing insurance details may result in additional costs.
Once all insurance information is received; Daly Drug LTC Pharmacy will make all reasonable efforts to bill the insurance before dispensing. However, I acknowledge that the final cost may vary based on my insurance coverage, deductibles, copayments, or other factors determined by my insurance provider.
I am aware of the various reasons why insurance may not cover medications, which may include, but are not limited to:
- Refill Too Soon Rejections: Insurance companies often have specific guidelines regarding the frequency of medication refills. If a refill is requested before the designated time frame, insurance may deny coverage.
- Over-the-counter Medications: Some medications are available over-the-counter and may not be covered by insurance. In such cases, I understand that I will be responsible for the full cost of the medication.
- Prior Authorizations: Certain medications require prior authorization from the insurance company before coverage is approved. If a medication requires prior authorization and it has not been obtained, I understand that I will be responsible for payment.
By signing below, I acknowledge that I have read and understood the terms and conditions of this authorization form.
This authorization will remain in effect until I provide written notice of revocation to the pharmacy.