2025 Surprise Lake Camp Pharmacy Form

INSTRUCTIONS

Welcome! We're delighted to have your child joining us at Surprise Lake Camp this summer. Please complete the following form as soon as possible to ensure a seamless experience. Remember, prescriptions must be submitted no later than June 4, 2025, to avoid any late fees.

IMPORTANT: Your child's registration process is not complete until we receive their prescriptions from their doctor. Please arrange for timely delivery. For a more detailed overview of our process, you can download 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*

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 Surprise Lake Camp for:*

Full Summer (6/27 - 8/17)Session 1 (6/27 - 7/27)Session 2 (7/29 - 8/17)Mini Camp (7/15 - 7/27)Get your Feet Wet - **Complete this form & send medications with child & notify camp**

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

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)*

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

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 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

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

Back of Prescription Insurance Card

Front of Prescription Card

Back of Prescription Card

PHARMACY FEE: There is no fee for all completed Pharmacy forms received by June 6, 2025. A Pharmacy Form is deemed complete when it is fully filled out and all required prescriptions have been received by the Pharmacy. A late fee of an additional $100 will be assessed for all Pharmacy Forms received on or after June 5, 2025. It is imperative that the Pharmacy receives all prescriptions in a timely manner. Any prescription received by the Pharmacy later than June 4, 2025, may have a delayed delivery and not be available when Camp commences. For second session, forms received after July 11th, will have a $100 late fee.

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.

I authorize the pharmacy to contact the Insurance company for insurance verification.*

Initial

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

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.*

Initial

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

Initial

My Products*

Camper Registration

$ Free Quantity

Late FeeFee for forms filled out after June 5, 2025 for Full Summer & 1st Session or July 11, 2025 (2nd Session). If you believe you are seeing this in error, please 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

2025 Surprise Lake Camp Pharmacy Form

Medication & Vitamins

PRESCRIBING PHYSICIAN

SECONDARY PHYSICIAN INFORMATION

HOME PHARMACY

INSURANCE INFORMATION

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