Release of Information Consent Form

I verify that the information provided to Community RX Help (the agency) is complete and accurate to the best of my knowledge and may be used by the agency, my physician, and the pharmaceutical companies and/or their agents or authorized designee to determine my eligibility for help with prescription medications.  I certify, by my signature below, that I am currently unable to pay for my prescriptions and have requested the agency’s help in obtaining needed medications.

I understand that, at such time as I obtain prescription coverage or have the financial resources to pay for the cost of the pharmaceutical product(s), that I will notify this agency of such change in my coverage or financial status.  I understand that, by my signature, any and all information that I provide will be shared with my physician and all pharmaceutical companies that produce a medication for which I am seeking assistance.  The agency agrees that no information will be shared with any entity, public or private, beyond which is necessary for participation in the program.

I understand that the pharmaceutical programs retain the right to modify or terminate their programs without prior notice and to determine my eligibility for their programs. I agree to release the agency of all liability related to these actions by the pharmaceutical companies.

I understand and agree that, through this program, medications may take up to 2 months or more to be received and I release the agency of all liability related to this possible delay.

1. Obtain needed medications through other means until medications are received through efforts of the agency.
2. Participate fully in the program, including the completion of applications and reporting any changes to income, insurance coverage, medication dosage or mailing address in a timely fashion.
3. Pick up or arrange to pick up any medications delivered my physician’s office in a timely manner.
4. Report the receipt (or NON-receipt) of medications to the agency in a timely manner.
5. Report to the agency when I have 30 days supply of medications to initiate a refill or a new application, if needed.

I understand that I am seeking help and agree to conduct myself, on the phone and in the office, in a manner that is appropriate and that inappropriate behavior may result in the termination of services rendered through the agency.  I understand that no medications are kept on the agency’s premises.

I understand that Community RX Help is a private (non-government), not for profit agency that is primarily funded through private contributions.

Important: After you submit this form please return to our website at communityrx.com and complete the other required forms. Thank You.