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
Patient's Name:
Patient's DOB:
I authorize Freedom Pharmacy to release medical and billing in formation to the following (other than self or physician offices): LIST ALL
Name:
Address:
Address:
Name:
Averte, 2122 Lower Plain, Bradford, VT 05033
GUARANTEE OF PAYMENT
This is to certify that we, Freedom Pharmacy, will receive reimbursement from the guarantor listed below for prescriptionmedications, over-the-counter products, co-pays, administration fees and any non-covered medications/products/services for the patient listed above for products/services rendered.

SEND BILLS TO PATIENTSEND BILLS TO GUARANTOR LISTED BELOW
Name of Guarantor:
Address of Guarantor:
Phone Number:
Guarantor Signature:

Clear
Date

MonthDayYear
Date
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)
Patient Signature:

Clear
Should be Empty:

Medical release