[Custom Rx Shoppe] New Patient Packet

Prescription Billing Information

In order for Custom Prescription Shoppe to make a smooth transition as your preferred pharmacyprovider, we need the following information:
Resident Name

First NameLast Name
Resident Social Security
Date of Birth

MonthDayYear
Date
Community/Facility
Insurance/Payment Information (we must have a copy of the front and back of the insurance card):

Private PayVAGroup Health Private
Private Insurance Company
Member Id
Welfare / DSHS Pic Code
Medicare #
Other
Responsible Party and Release of Medical Information

I understand that I am financially responsible to Custom Prescription Shoppe, LLC for all charges incurred by the above-named resident including collection fees, attorney fees, and court costs. If the resident has state Medicaid, all non-covered medications and supplies will be billed to the resident, unless prohibited by regulations. I understand that I am responsible for payment of any medication or other charges to the above-named resident not covered by third-party insurance while he/she resides at this facility.

Statement balances will be paid immediately upon receipt unless other arrangements are made. If the amount is not paid in full within thirty (30) days of the due date, a late charge may be incurred, computed at one percent (1%) of the unpaid balance for each month, or part thereof, that is not paid in full. If the balance is not paid in full within thirty (30) days or a payment plan has not been arranged and agreed upon, provision of medications and supplies may be suspended.

I hereby authorize any holder of medical and/or insurance information about the above-named resident to disclose such information to Custom Prescription Shoppe. I further authorize Custom Prescription Shoppe to disclose any medical and/or insurance information concerning the above-named resident in its possession to other professional personnel involved in patient care such as a physician, a registered nurse, a pharmacist, or other such personnel, and to any insurer or other third-party payer who may be responsible to Custom Prescription Shoppe. Any disclosures will be made in compliance with HIPAA guidelines and other state and federal regulations.
Responsible Party
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Cell Phone
Is this where yo send the statement?
Relationship to Resident

selfspouseson/daughter guardianother
Signature

Clear

Consent to Receipt of Medications in Non-Child Resistant Containers
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
I hereby authorize and agree that all medications provided to me shall be delivered and received in a non-child-resistant container.
Patient Signature

Clear
Signature Date

MonthDayYear
Date

Delivery Authorization

In order for Custom Prescription Shoppe to begin delivery services of your medications,we need the following information:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this where we will deliver your medications?
Delivery Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number at Delivery Address
Please enter a valid phone number.
Special Delivery Instructions
Authorization to Discuss Pharmacy Services:

By signing below, I do hereby authorize Custom Prescription Shoppe to discuss my prescription needs and payment information with the following individuals:
Person 1
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Type a question
Person 2
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Type a question
Person 3
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Type a question
Signature

Clear
Signature Date

MonthDayYear
Date

Acknowledgement of Receipt of the Notice of Privacy Practices

I acknowledge that I have received a copy of the pharmacy’s Notice of Privacy Practices:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Signature

Clear
Signature Date

MonthDayYear
Date
Documentation of Good Faith Effort

The pharmacy made a good faith effort to obtain a written acknowledgment of the individual’s receipt of the Notice, but a written acknowledgment was not received for the following reason:
Reason being

Individual refused to signIndividual was not able to sign. (Please specify below)Emergencyother (Please specify below)
Please specify the reason

EFFECTIVE 10/1/2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

As part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA, the pharmacy has created this Notice of Privacy Practices (Notice). This Notice describes the pharmacy’s privacy practices and the rights you, the individual, have as they relate to the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that could be used to identify you, as it relates to your past and present physical and mental health care services. The HIPAA regulations require that the pharmacy protect the privacy of your PHI that the pharmacy has received or created.

This pharmacy will abide by the terms presented within this Notice. For any uses or disclosures that are not listed below, the pharmacy will obtain a written authorization from you for that use or disclosure, which you will have the right to revoke at any time, as explained in more detail below. The pharmacy reserves the right to change the pharmacy’s privacy practices and this Notice. Revisions to the Notice will be posted in the pharmacy and upon your request, provided to you in a paper format.

HOW THE PHARMACY MAY USE AND DISCLOSE YOUR PHI

The following is an accounting of the ways that the pharmacy is permitted, by law, to use and disclose your PHI.

Uses and disclosures of PHI for Treatment:

We will use the PHI that we receive from you to fill your prescription and coordinate or manage your health care.

Uses and disclosures of PHI for Payment:

The pharmacy will disclose your PHI to obtain payment or reimbursement from insurers for your health care services.

Uses and disclosures of PHI for Health Care Operations:

The pharmacy may use the minimum necessary amount of your PHI to conduct quality assessments, improvement activities, and evaluate the pharmacy workforce.

Disclosures for judicial and administrative proceedings:

The pharmacy may disclose PHI about you in the course of any judicial or administrative proceedings, provided that proper documentation is presented to the pharmacy.

Disclosures for law enforcement purposes:

The pharmacy may disclose PHI about you to law enforcement officials for authorized purposes as required by law or in response to a court order or subpoena.

Uses and disclosures about the deceased:

The pharmacy may disclose PHI about a deceased, or prior to, and in reasonable anticipation of an individual’s death, to coroners, medical examiners, and funeral directors.

Uses and disclosures for cadaveric organ, eye or tissue donation purposes:

The pharmacy may use and disclose PHI for the purpose of procurement, banking, or transplantation of cadaveric organs, eyes, or tissues for donation purposes.

Uses and disclosures for research purposes:

The pharmacy may use and disclose PHI about you for research purposes with a valid waiver of authorization approved by an institutional review board or a privacy board. Otherwise, the pharmacy will request a signed authorization by the individual for all other research purposes.

Disclosures for business associates:

The pharmacy may disclose PHI about you to the pharmacy’s business associates for services that they may provide to or for the pharmacy to assist the pharmacy to provide quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.
FOR ALL OTHER USES AND DISCLOSURES

The pharmacy will obtain a written authorization from you for all other uses and disclosures of PHI, and the pharmacy will only use or disclose pursuant to such an authorization. In addition, you may revoke such an authorization in writing at any time. To revoke a previously authorized use or disclosure, please contact Sarah Pitts to obtain a Request for Restriction of Uses and Disclosures.

YOUR HEALTH INFORMATION RIGHTS

The following is a list of your rights in respect to your PHI.

Request restrictions on certain uses and disclosures of your PHI:

You have the right to request additional restrictions of the pharmacy’s uses and disclosures of your PHI. However, the pharmacy is not required to accommodate a request. If you wish to request additional restrictions, please obtain the form, Request for Restriction of Uses & Disclosures, from the pharmacy and return the completed form to the pharmacy or return to Sarah Pitts.

CONTACT INFORMATION

If you have any questions on the pharmacy’s privacy practices or for clarification on anything contained within the Notice, please contact:

The Custom Prescription Shoppe LLC
Sarah Pitts
5917 Portal Way
Ferndale, WA 98248
(360) 685-4270
Should be Empty:

Personal Information

Prescription Billing Information

Responsible Party and Release of Medical Information

Consent to Receipt of Medications in Non-Child Resistant Containers

Delivery Authorization

Authorization to Discuss Pharmacy Services:

Person 1

Person 2

Person 3

Acknowledgement of Receipt of the Notice of Privacy Practices

Documentation of Good Faith Effort

EFFECTIVE 10/1/2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

HOW THE PHARMACY MAY USE AND DISCLOSE YOUR PHI

Uses and disclosures of PHI for Treatment:

Uses and disclosures of PHI for Payment:

Uses and disclosures of PHI for Health Care Operations:

Disclosures for judicial and administrative proceedings:

Disclosures for law enforcement purposes:

Uses and disclosures about the deceased:

Uses and disclosures for cadaveric organ, eye or tissue donation purposes:

Uses and disclosures for research purposes:

Disclosures for business associates:

FOR ALL OTHER USES AND DISCLOSURES

YOUR HEALTH INFORMATION RIGHTS

Request restrictions on certain uses and disclosures of your PHI:

CONTACT INFORMATION