MedManager by Bouvier's
Concierge Medication Services Enrollment Form
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Address
Street Address
Facility/ Room # (if applicable)
City
State
Zip Code
Type of Residence/Services
*
Assisted Living
Group Home
Independent Living
SAMM
LMA
Packaging Requested
*
Multidose Dispill Cards
Single Dose Blister Packs
Vials
Primary Care Provider
Full Name
Phone Number
Known Allergies
Preferred Start Date
-
Month
-
Day
Year
Date
Emergency Contact/Responsible Party (if different from above)
Full Name
Phone Number
Emergency Contact/Responsible Party Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Use as Billing Address
Yes
No
Email Address
example@example.com
Relation to Patient
Medical Information
Current Medication List
Browse Files
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Choose a file
*If possible have lists signed by a provider to expedite processing
Cancel
of
Are there any medications being provided by mail order or specialty pharmacy? If so please provide what medications and who is the prescriber, or indicate "None"
*
Current Prescription Insurance Cards
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*If there are more than one please upload a picture of all including current Medicare card
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of
If unable to provide copies of current coverage above, please type information below
Medicare Number, Prescription Coverage: Member ID, Rx Group, Rx Bin, Rx PCN
Payment Information
For all MedManager customers a bank OR credit card information MUST be provided below to cover copays or amounts not covered by insurance. We will process payment once a month and charge details will be sent to the billing contact. If an outstanding balance is 90 days past due, medication services will cease.
Bank Routing
Bank Account Number
CC #
Expiration Date
Code
Billing Zip Code
Agreement to Payment and Tamper Proof Waiver
By typing my full name below I fully understand Bouvier Pharmacy’s payment policy, specifically that all Co-Payments, Deductibles, or non-covered items or services are the responsibility of the undersigned and will be payable monthly. I further understand that this packaging is not a child proof system and I accept full responsibility for keeping these medications in a safe place away from children or other people not intended to take them.
SIGNATURE OF AUTHORIZED/RESPONSIBLE PARTY
*
First Name
Last Name
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