• Medical release

    Medical release

  • 434 Hurricane Lane, Williston, VT 05495 802-655-3544 or 1-800-638-1675 Fax 802-655-0123 www.freedompharmacyvt.com

  • I authorize Freedom Pharmacy to release medical and billing in formation to the following (other than self or physician offices): LIST ALL

  • Averte, 2122 Lower Plain, Bradford, VT 05033

  • GUARANTEE OF PAYMENT

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  • Regardless of whether or not the patient has prescription insurance benefits, the patient and/or guarantor (payee) will need to make payment arrangements in advance with our billing department in the form of a credit card or checking/savings account in order for services to start (see attached automatic payment form)

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