*****Please send a photocopy of the insurance card (Front and Back) to fax 615-410-4791*****

Choose Credit Card or Banking information required. Please fill out one below:

Should you wish to provide the details below in a secure link, please request at the email: rx@pharmalifecp.com

BANKING INFORMATION

PLEASE SELECT FROM THE FOLLOWING PAYMENT OPTIONS BELOW

• ❖ The Resident/Responsible Party understands that the use of Pharmalife Pharmacy and the services provided by Pharmalife Pharmacy is optional.
• ❖ The Resident/Responsible Party understands and agrees that Pharmalife Pharmacy may make automated phone calls, emails, and text messages as reminders to pay bills and/or collect payment.
• ❖ The Resident/Responsible Party agrees that Pharmalife Pharmacy may bill the banking information or credit card listed above if payment is not received by the invoice due date.
• ❖ The Resident/Responsible Party understands that if payment is not received, Pharmalife Pharmacy may discontinue all services provided and may report the bill to credit reporting agencies.
• ❖ The Resident/Responsible understands that if payment is not received, a 1.5% per month may be charged on balances over 30 days past due.
• ❖ The Resident/Responsible Party understands that not all commercial insurance covers Long Term Care services. If your plan does not cover these services, the Resident/Responsible party agrees to pay the fee for Pharmalife services provided and will be itemized on your invoice.

Notice of Privacy Practices & Patient Bill of Rights

This is an agreement for pharmacy services with Pharmalife Community Pharmacy

I agree to the following terms and conditions for pharmaceutical services:

• HIPAA AUTHORIZATION:
• RELEASE OF INFORMATION
• MEDICAL RESPONSIBILITY
• PATIENT RESPONSIBILITY
• FACILITY INVOLVEMENT
• FINANCIAL RESPONSIBILITY
• PAYMENT
• UNPAID INVOICES:
• WITHHOLD SERVICES