New Patient Financial Agreement & Responsible Party Information

New Patient Financial Agreement & Responsible Party Information

This form is securely hosted and HIPAA-compliant. All information entered is encrypted and protected in accordance with federal healthcare privacy standards. Sensitive personal and billing information is accessed only by authorized Savers Long Term Care Pharmacy staff.
Billing / Responsible Party Information

Please provide information for the person financially responsible for billing.
Resident Name*

First NameLast Name
Date of Birth*

MonthDayYear
DoB
Person Responsible for Billing (POA / Guarantor)*

First NameLast Name
Mailing Address - Where statements are sent*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary / Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Identification Information

Information used for billing and insurance verification.
Drivers License *

Cancelof
Social Security Number*
Medicare Number (MBI)
(Red White and Blue Card)
Insurance & Payment Information

Upload all insurance cards and complete insurance details.
Please upload clear images of the FRONT AND BACK of all insurance cards.
Insurance Card Upload (Front and Back)

Cancelof
Primary Insurance Carrier
BIN #
PCN #
ID #
Group #
YesNo
Tricare Only: Sponsor’s Full Billing Verification Number
Financial Responsibility & Authorization

Acknowledgments regarding financial responsibility and payment.
Signature Authorization

Please provide your electronic signature and authorization.
Electronic Signature (Resident or Responsible Party / Guarantor)*

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Printed Name*
Date (MM/DD/YYYY)*

MonthDayYear
Date
I acknowledge receipt of the pharmacy’s Notice of Privacy Practices.
I authorize Savers Long Term Care Pharmacy to contact me via phone, text, or email regarding medications, billing, or care coordination.
Emergency Contact
Emergency Contact Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please verify that you are human*
Should be Empty:

New Patient Financial Agreement & Responsible Party Information

Billing / Responsible Party Information

Identification Information

Insurance & Payment Information

Financial Responsibility & Authorization

Signature Authorization

Emergency Contact