New Client Intake Package

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1 (P) (P) MEDS (F) (New Client Fax) New Client Intake Package Welcome and thank you for choosing Ready Meds Pharmacy for your pharmacy needs! To provide the highest level of care and to expedite the intake process the following information is requested by your Pharmacist and/or required by state regulations: 1. New Client Form (page 1) Completed with list of drug allergies, primary care physician, previous pharmacy, and Power of Attorney (POA) contact information. 2. Patient s Insurance Information This may be a copy of patient s current pharmacy insurance card, driver s license, and/or social security card. 3. Current Medication List If patient is coming from a hospital or rehab center, provide a discharge summary. If patient is moving from another AFH or their private home to your AFH, provide a current medication list from a doctor s office or a copy of the previous AFH s MAR. 4. Release of Information / Authorization of Benefits Form (page 2) to be filled out by either POA/Payee or patient (if self-poa) This form allows the pharmacy to contact and correspond with other healthcare professionals in patient s care team. 5. Financial Agreement Form (page 3) to be filled out by POA/Payee or patient (if self-poa) The POA/Payee may set limitations such as only bill for zero copays so pharmacy staff will contact them whenever insurance requires a copay. 6. Credit Card Authorization Form (page 4) to be filled out if POA/Payee requests for auto payments and/or is required if patient is self-poa We require that a credit card is stored for billing purposes for patients who manage their own finances. Clients who do not have a credit card must inform our billing department of their case. Please fax to or to readymedspharmacy@gmail.com once you have acquired the necessary documents Ready Meds Pharmacy

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3 (P) (P) MEDS (F) (New Client Fax) RELEASE OF INFORMATION / AUTHORIZATION OF BENEFITS I hereby authorize the holder of medical or other information about me to release to the Social Security Administration, Centers for Medicare and Medicaid Services, and its intermediaries or to any third party payer, as required, any information needed for this related health claim. I permit a copy of this authorization be used in place of the original and request payment of medical insurance benefits to Jolly s Pharmacy DBA: Ready Meds Pharmacy, who accepts assignments. I hereby authorize release to this company and all of my medical records pertaining to my medical history, services rendered or treatments received from my physician(s) or hospital. I also authorize release of medical information to auditors authorized by the organization for the purpose of certification, licensure, or accreditation. I acknowledge that I have received a copy of the pharmacy s Notice of Privacy Practices (HIPAA). Resident s Name: Resident s Date of Birth: Resident or Power of Attorney Signature Resident or Power of Attorney Printed Name Date Relationship to Resident if Power of Attorney The Facility made a good faith effort to obtain a written acknowledgement of the individual s receipt of the Notice but a written acknowledgement was not received for the following reasons: Resident and/or Power of Attorney refused to sign Resident and/or Power of Attorney unable to sign (please specify below): Adult Family Home Provider Signature Date A copy of the Notice of Privacy Practices may be obtained via our website at readymedspharmacy.com/forms PAGE 2

4 Resident Payment Guarantee and Financial Agreement Form Resident s Name: Date of Birth: Facility s Name: I UNDERSTAND AND ACCEPT THE FOLLOWING TERMS AND CONDITIONS: I understand that the medications furnished to the above-named resident are not packaged in childproof containers. I agree that the facility 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 payers, including Medicare and Medicaid I understand that medications that are delivered to the above-named facility and subsequently discontinued or modified by the above-named resident s physician or otherwise not used by the above-named resident for any reason cannot be returned for credit. I understand that all medications, once delivered are not returnable per WAC , and I will be responsible for the full amount due. I understand that the statements printed at the beginning of the month are for medications sent the previous month, therefore should the above-named resident moved out the above-named facility or passed away I am still obligated to pay the final balance by the end of the statement month. I agree to pay the entire amount due by the end of the statement month unless prior arrangements were made with Ready Meds Pharmacy s billing department. If full payments are not received by the end of the month, I agree to pay a finance charge of 2.00% per month or a minimum service charge of $5.00 whichever is greater on the leftover balance. I understand that if no payment or partial payment were received for the previous month, Ready Meds Pharmacy may reserve the rights to refuse services for the above-named resident. If your account becomes 120 or more days delinquent, Ready Meds Pharmacy may reserve the rights to send your account to collection. I agree to pay all costs of collection, including court costs and attorney fees, for all delinquent balances. There will be a closing fee of 50% of the final balance upon closing of the account. I agree to pay Ready Meds Pharmacy a fee of $40.00 per RCW 62A (b)(1) if for any reason a check issued for the above-named resident is not honored by the financial institution. Ready meds Pharmacy does not accept postdated checks. SIGNATURE OF RESPONSBILE PARTY OR PAYEE DATE PRINT NAME OF RESPONSBILE PARTY OR PAYEE PHONE # ADDRESS OF RESPONSBILE PARTY OR PAYEE CITY, STATE, ZIP CODE * * * * * Please return completed form to Ready Meds Pharmacy within 7 days of moving in * * * * *

5 Credit Card Authorization Form Card Type: Visa/MasterCard/AMEX/Discover Name on Card: Billing Address City/State Zip Code: Card Number: Expiration Date: Security Code: (CVV) Patient s Name: Patient s DOB: Name of Assisted Living Facility: I, authorize Ready Meds Pharmacy, Inc to charge automatically to my credit and/or debit card outlined above monthly for payments owed on the monthly statement for the client above. I understand that I will continue to receive a monthly statement for my information and review. I acknowledge that Ready Meds Pharmacy will be storing my credit card information on a secure server for billing purposes only. I understand that upon receiving notification of the client above leaving the facility above, Ready Meds Pharmacy will charge any remaining balance on the client s file to close out the account. I understand that to cancel this arrangement, I will have to contact Ready Meds Pharmacy in writing directly. Cardholder Signature: Date: PAGE 4

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