PPP Resident/Responsible Party Agreement

NAME OF RESIDENT*

GENDER*

MALEFEMALEOTHER

DATE OF BIRTH*

Date

ASSISTED LIVING FACILITY NAME*

NAME OF PERSON TO BE BILLED/POA*

ADDRESS OF PERSON TO BE BILLED/POA*

Street Address

Street Address Line 2

CityState

Zip Code

HOME PHONE OF PERSON TO BE BILLED/POA

Please enter a valid phone number.

CELL PHONE OF PERSON TO BE BILLED/POA*

Please enter a valid phone number.

RELATIONSHIP TO RESIDENT*

Type of Coverage*

Private PayPrivate Third-Party InsuranceMedicaidOther

INSURANCE CARRIER NAME*

RX BIN #*

RX PCN #*

POLICY NUMBER/SUBSCRIBER ID*

RX GROUP #*

Front of Prescription Insurance Card

Back of Prescription Insurance Card

I agree that community personnel are authorized to order purchases and charges on behalf of the above-named resident.
I agree to pay all charges incurred by the above-named resident that are not paid for by third party payors, including Medicaid, and additional charges for specially-packaged medications.
I will pay the entire amount due within terms of the statement in accordance with each statement. I also understand that a late charge will be added to the balance owed for delinquency of 30 days or more.
I agree that in order for the resident's account to remain active, payment for billed charges must be made promptly pursuant to these terms. Accounts >/= 90 days past due may be placed on hold and future medications and services may not be supplied.
I agree to pay all costs of collection, including court costs and attorney's fees, for all delinquent balances.
I understand that the medications furnished to the above-named resident are not packaged in child-proof containers.

I consent to the release of personal and medical information to any third party payor, governmental agency providing benefits, or other person(s)/entity liable for my treatment charges. In addition, I consent to a similar release of information, as shall be necessary, to initiate and continue my use of pharmacy, laboratory, or other community resources, and/or for transfer to another health care facility.

Resident or Responsible Party/Guarantor Signature*

Date*

Date

As a recurring automatic monthly transaction, I would like you to charge my credit card the full account balance:*

YesNo

After submitting this form, please call Paradise Professional Pharmacy staff at (410) 744-5959, ext 3, with the following information to successfully enroll in automatic payments:

Resident Name
Name of Facility
Type of Credit Card (Visa/Mastercard/Discover/American Express accepted)
Name on Credit Card
Credit Card Number
Credit Card Expiration Date
Credit Card CVV Code
Billing Zipcode

TYPE OF CREDIT CARD*

CREDIT CARD NUMBER*

CREDIT CARD EXPIRATION DATE*

Date

CREDIT CARD CVV CODE*

Resident or Responsible Party/Guarantor Signature*

Date*

Date

Paradise Professional Pharmacy Resident/Responsible Party Agreement

BILLING INFORMATION

PAYMENT/INSURANCE INFORMATION

I UNDERSTAND AND ACCEPT THE FOLLOWING TERMS AND CONDITIONS:

PAYMENT OPTION: AUTOMATIC MONTHLY CREDIT CARD CHARGES