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

    Enclosed you will find five documents that need your immediate attention. We do require that you fill out these forms and return to the address above as soon as possible and before services can be started.

    1. Demographic Intake sheet

    This sheet asks for your basic demographic and insurance information to get you set up in our system. Please complete as thoroughly as possible to avoid follow up questions. There is also an area to complete a Non-Safety Cap Request, this is required as the Medicine-On-Time packages are not child resistant.

    Please list all the medications you take including any over the counter medications. If you take your medications at a certain time of the day please indicate that as well.

    3. Notice of Privacy Practices

    Please take a minute to read our copy of our Notice of Privacy Practices. Afterwards, please sign the Acknowledgment to send back to us.

    4. Medical Release Form & Guarantee of Payment Form

    We also need you to fill out a medical release if you wish for us to be able to discuss your healthcare and/or related finances with anyone other than yourself. The second part of this form is a guarantee to the pharmacy that, if you receive medications/products that are not covered by your insurance or you have insurance co-payments for medications that are covered; you or your guarantor (payee) will be responsible for the payments.

    5. Automatic Credit Card or ACH Payment Authorization Form

    In order to join the Medicine-On-Time program, Freedom Rx will need to have automatic payment information on hand before services are started. Please fill out the form, sign, date and send back to us with the other forms. If you are unable to provide a credit card or savings/checking account for automatic payment but would still like to enroll in the Medicine-On-Time Program, please call us so that we can discuss other options.

    Thank you for taking the time to complete these forms.

    The products and/or services provided to you by Freedom Pharmacy are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.

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

  • Address: 2122 Lower Plain, Bradford, VT 05033

  • Phone: Averte House Phone: 

  • Primary Doctor: TBD

    Other Doctor: TBD

  • Need Medication Administration Record (MAR): Yes MAR is needed

  • Delivery Method: Delivery

    Requested Cycles: 28 Day (No Fee)

    Frames Needed: No Frames Needed

    Requested Start Date: TBD

     

  • Are PRN (as needed) medications ok in Vials?: No, Please Bubble Pack

    Federal law requires that your medication be dispensed in a container with a child resistant or safety cap. If you would like your prescriptions in Medicine-On-Time packaging and with an "Easy-Open" lid, please sign below:

    I request that my prescriptions and all refills of my prescriptions be dispensed in "Easy-Open" or Non-child resistant containers.

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