Good Day Pharmacy (LTC) Pharmacy Agreement

PHARMACY AGREEMENT

This form authorizes Good Day Pharmacy to provide medications to the individual (resident) named below and provides that financial responsibility incurred from the medications will be paid by the resident, spouse or Legally Responsible Representative (Guarantor).
Community Name*
Designate Good Day Pharmacy as one of the following:

Primary Pharmacy (Good Day Pharmacy will fill and deliver all medication orders and changes unless otherwise specified)Emergency Pharmacy (Good Day Pharmacy will profile all medication orders and changes. Medication orders and changes will only be filled upon request and must be authorized by resident or POA)
Emergency Pharmacy Only Residents: Any medication(s) filled and delivered by Good Day Pharmacy for residents designated as “Emergency Pharmacy Only” will incur a $25 delivery fee per occurrence.

This fee reflects the additional coordination and operational effort required, including:
- Communicating with the resident’s primary pharmacy, mail-order service, or prescriber to ensure safe, accurate, and timely access to needed medication.
- Attempting to process insurance claims to help minimize out-of-pocket costs to the resident whenever possible.
- Preparing, packaging, and delivering the medication to the facility or resident in accordance with pharmacy regulations.
- Maintaining proper documentation and records of the medication dispensed for accountability and compliance purposes.
This fee helps offset the resources needed to provide urgent support to non-primary pharmacy patients and ensures continuity of care in critical moments. We remain committed to supporting residents and facilities, even in situations where we are not the pharmacy of record, and appreciate your understanding of the associated service costs.
Resident Name*
Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resident Date of Birth*

MonthDayYear
Date
Resident Allergies (if known):
Medicare Number (Red, White, and Blue Card)
This form is encrypted and HIPAA Compliant
Social Security Number
This form is encrypted and HIPAA Compliant
Primary Care Physician Name (if known)
Responsible Party

Used for coordinating care and communication
Responsible Party Name*
Relationship to Insured*
Responsible Party's Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address (to be used for when important information is mailed (example: billing statements)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescription Insurance:

To be used to bill insurance for prescriptions. Please photocopy both sides of the prescription card and attach)
Does the resident have Medicaid Insurance?*

YesNo
Front of Prescription Insurance Card
If Yes, Please indicate Medicaid ID here
Back of Prescription Insurance Card
Second Prescription Insurance Card (if necessary)
Insurance Company Phone Number (if known)
Please enter a valid phone number.
Insurance Company Name
Statement / Payment Information
- Each Month, an itemized statement including insurance copays and non-covered products will be sent along with a self-addressed envelope for your mailing convenience. The 'copays' for medications covered by insurance are noted with a lowercase 'c' on the far right side of the amount listed for each item.
- This statement is payable directly to Good Day Pharmacy upon receipt. If payment is not received by the last day of the month, a finance charge of 8% APR of the balance due on all unpaid balances every sixty days (60) will be assessed. Your bill can be paid anytime on GoodDayPharmacy.com.
- If you prefer, we have two convenient ways to pay your bill automatically. See the attached form 'Authorization Agreement for AUtomatic Payments' for details.
All pharmacies doing business in Colorado are required by Colorado State Law to report all controlled substance prescriptions they dispense to the Prescription Drug Monitoring Program (PDMP) operated by the Colorado Board of Pharmacy. Prescription information in the PDMP may be accessed for limited purposes by persons specified by state law. For more information, you may contact the Board of Pharmacy at (303) 894-7800 or www.dora.state.co.us/pharmacy.
By signing this Agreement, I:
- Authorize Good Day Pharmacy to provide medications to the resident named above effective on the date indicated below.
- Authorize Good Day Pharmacy to substitute generic products, when available, as allowed by my physician and applicable law to contain costs.
- Agree to accept full financial responsibility and guarantee payment of all charges for pharmacy services provided by Good Day Pharmacy that are not covered by third-party payers, including Medicare Part D and Medicaid.
- Acknowledge and understand that Good Day Pharmacy cannot accept returns of medications that are not in compliance with the applicable State Board of Pharmacy rules and regulations.
Notice of Privacy Practices (NOPP):

Under applicable law, we are required to maintain the privacy of your Protected Health Information (PHI) and to provide you with notice of your legal duties and privacy practices with respect to PHI. Please visit our website at gooddaypharmacy.com and select PRIVACY POLICY for details. By signing this agreement, you are acknowledging that you been notified of Good Day Pharmacy's Privacy Practices. If you have questions after reading the attached notification, please contact a pharmacy staff member.
Signature of Resident

Clear
Date

MonthDayYear
Date
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PHARMACY AGREEMENT

Responsible Party

Prescription Insurance:

Statement / Payment Information