2025 Ramah Berkshires Pharmacy Form

2025 Ramah Berkshires Pharmacy Form
INSTRUCTIONS

Welcome! We're delighted to have your child joining us at Camp Ramah in the Berkshires this summer. Please complete the following form as soon as possible to ensure a seamless experience.

IMPORTANT: Your child's registration process is not complete until we receive their prescriptions from their doctor. To avoid any late fees, prescriptions must be submitted no later than three weeks prior camp start date. Please arrange for timely delivery. For a more detailed overview of our process, you can reference our Family Infographic and access additional FAQs on our webpage linked here.

Prescription Delivery Options:

1. E-Scribe (preferred): Your doctor can electronically submit prescriptions using our information below.

2. Mail: Prescriptions can be mailed to:

Drug World of Cold Spring, LLC
55 Chestnut St.
Cold Spring, NY 10516
Phone: 845-265-6352
Attention: Caitlin Chadwick

Billing Information: Please keep an eye out for the bill for all co-pays and related fees. All bills must be paid in order for medications to be delivered.

For any billing inquiries, please contact Caitlin Chadwick at 845-265-6352 ext. 129 or camp@drugworld.com.

Thank you for your cooperation!

Warm regards,
The Drug World Team
Camper's Name*

First NameLast Name
Camper's Date of Birth*

MonthDayYear
Date
CAMPER'S GENDER (for insurance purposes only)*

FEMALEMALE
CAMPER'S GENDER IDENTITY

FEMALEMALENON-BINARY
Parent/Guardian Name*

First NameLast Name
My child will be attending Ramah Berkshires for:*

Full Summer (6/25 - 8/14)Session 1 (6/25 - 7/20)Session 2 (7/23 - 8/14)Mini Session A (7/21 - 7/27)Mini Session B (7/28 - 8/10)
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Primary Phone Number*
Please enter a valid phone number.
Does your Child have any allergies?

YesNo
List Allergies Here
Medication & Vitamins
Please list ALL of your child’s medications in the section below. For each medication, provide the following information:
- Type (prescription, nutritional, or over-the-counter)
- Manufacturer (for nutritional supplements only)
- Medication name
- Strength
- Frequency (e.g., "1x daily" or "as needed")
- Form (for OTC medications, specify whether it’s a capsule, gummy, chewable, tablet, spray etc.)
- Times required for dispensing
- Generic or Name Brand preference
EXAMPLE 1: Prescription Medications
(Medication Name) Concerta - (Strength) 36mg - (Frequency) 2x daily - (Dispensed) Breakfast & Lunch - (Generic) Okay

EXAMPLE 2: Over-the-Counter Medications
(Manufacturer Name) Children's Zyrtec - (OTC Name) Cetirizine - (Strength) 10mg - (Frequency) 1x daily - (Form) Grape Chewable - (Dispensed) as needed - (Generic) name brand preferred

EXAMPLE 3: Nutritionals
(Manufacturer Name) Nordic Naturals - (Medication Name) Ultimate Omega Jr - (Strength) 680mg - (Form) Soft Gels - (Frequency) 1x daily - (Dispensed) Breakfast (Generic) name brand preferred
Does your child take any Prescription Medication?*

YesNo
Enter Prescription Medications here (only one medication per line)*
Does your child take any Over-the-Counter Medications?*

YesNo
Enter Over-the-Counter Medications here (only one medication per line)*
Does your child take any Nutritionals?*

YesNo
Enter Nutritionals here (only one medication per line)*
PRESCRIBING PHYSICIAN
Physician's Name

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.
Physician's Fax Number
Please enter a valid phone number.
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECONDARY PHYSICIAN INFORMATION
Physician Name

First NameLast Name
Physician Phone
Please enter a valid phone number.
Physician Fax
Please enter a valid phone number.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHARMACY
Home Pharmacy Name
Home Pharmacy Phone Number
Please enter a valid phone number.
Home Pharmacy Fax Number
Please enter a valid phone number.
Home Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE INFORMATION
Pharmacy Insurance Carrier
Member ID #
RX Group #
RXPCN #
RXBIN #
Primary Subscriber's Name

First NameLast Name
Camper's relationship to Subscriber
Front Prescription Insurance Card

Cancelof
Back of Prescription Insurance Card

Cancelof
Front of Prescription Card
Back of Prescription Card
PHARMACY FEE: A $100 fee is charged for pharmacy services. The Pharmacy Form is considered complete when fully filled out and all required prescriptions have been received. A late fee of $100 will be applied to all Pharmacy Forms submitted after May 5, 2025. It is crucial that the Pharmacy receives all prescriptions on time. Any prescription received after May 28, 2025, may experience delays in delivery and may not be available when camp begins.

RELEASE OF INFORMATION (Title 42 CFR): The Undersigned hereby permits Drug World Pharmacy 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 Authorization. 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 Drug World Pharmacy. This consent is subject to revocation at any time except to the extent that Drug World 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 Drug World includes all available sources of coverage, and assigns to Drug World, sufficient monies from said insurance to pay for the patient's prescription 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 Drug World 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 Drug World and authorizes Drug World to submit a claim to Medicare for payment.

FOR CO-PAYS AND FEES 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-counter items I order, which I agree will be billed directly to my credit card by the Pharmacy. I authorize Drug World to charge the credit card indicated in this authorization form, and I certify that I am an authorized user of this credit card.
PLEASE INITIAL THE FOLLOWING
I authorize the pharmacy to contact the Insurance company for insurance verification.*

Clear
Initial
I authorize the pharmacy to bill my credit card directly. *

Clear
Initial
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 and deductibles, which I agree will be billed directly to my credit card by the pharmacy.*

Clear
Initial
Signature of Guarantor: I acknowledge that all insurance information I have provided is accurate.*

Clear
Initial

My Products

Camper Fee for Pharmacy ServicesThis portion is the fee for packaging the campers medication.

$100.00

Late FeeFee for forms filled out after May 5, 2025. If you believe you are seeing this in error, contact Drug World directly.

$100.00 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

2025 Ramah Berkshires Pharmacy Form

Medication & Vitamins

PRESCRIBING PHYSICIAN

SECONDARY PHYSICIAN INFORMATION

HOME PHARMACY

INSURANCE INFORMATION

PLEASE INITIAL THE FOLLOWING