Value Specialty Patient Packet Full

  • Signature Page

    Please complete ALL information below and click the checkbox next to the title of the individual documents indicating that they have been reviewed and sign where indicated.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Please review the following documents using the links below before making your next selection(s):

    New Patient Agreement
    HIPAA Notice of Privacy Practices
    Patient Bill of Rights and Responsibilities
    Medication Disposal

  • The following documents have been reviewed and any questions directed to Value Specialty Pharmacy Team Members for clarification if necessary.*
  • Date of Signature:*
     - -
  • Format: (000) 000-0000.

  • Authorization for Communication of Protected Health Information with Caregiver/Child/Spouse:

    This Value Specialty Pharmacy (VSP) authorization is for use if you wish to have a spouse, parent, adult, child, or caregiver have access to your medical and health information on an on-going basis to assist with your care and maintain your information as well as authorize refills of your medication on your behalf.
  • Date of Patient Signature:
     - -
  • Patient Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • This information will be utilized only for the provision of health care and may be rescinded by the patient at any time by contacting a Value Specialty Pharmacy Member.

  • Assignment of Benefits

    I hereby authorize Value Specialty Pharmacy to bill my insurance carrier or any other payment source. I assign all benefits and authorize payment directly to Value Specialty Pharmacy for any benefits otherwise payable to me for all claims for such services provided or submitted prior to, or after, the date provided on this form. I understand that I am financially responsible for payment for all services rendered and that I am obligated to pay all charges that may be denied by my prescription benefit carrier(s). This assignment and authorization in no way releases me from said responsibility and imposes no obligation on Value Specialty Pharmacy to collect money on my behalf.

  • I have read, understand and agree to all the information above. A photocopy of this agreement may be used as though it were an original.

    This Assignment of Benefits will be effective until revoked by me in writing. Such revocation shall have a prospective effect only.

  • Signature Date:
     - -
  • Signature Date:*
     - -
  • Should be Empty: