RESIDENT / RESPONSIBLE PARTY INFORMATION
Fill out all that apply (notify pharmacy of status changes):
Prescription Drug Insurance / Medicare Part D PDP:
Provide a copy (front & back) of private insurance, Medicare or Medicaid, insurance card(s)
Click to download and/or print:
Forum Extended Care Services, Inc., II (PHARMACY) agrees to provide medications and other pharmaceutical items as ordered by the resident’s physician in accordance with the following terms:
I authorize PHARMACY to submit claims to Medicare B and D, Medicaid, and/or commercial insurance carriers for payment of covered services rendered on my behalf. I request that payment of authorized benefits be made on my behalf and authorize payment of my insurance benefits directly to PHARMACY, which payment will not exceed the balance due on my account. I authorize any holder of medical or other information about me to release to PHARMACY and/or the Center for Medicare and Medicaid Services, its agents and/or insurance companies, any information needed to determine these benefits or benefits for related services.
In the event there are any outstanding pharmacy charges that all reasonable collection efforts fail to recoup, I hereby grant to the PHARMACY the absolute right to file a lien on all real property or interest therein owned in whole or in part by the resident or responsible party identified below to satisfy this debt.
I certify that the information given by me is correct and I have read or had this document read to me, and I understand its contents and intents. I also certify that I am the resident, or am duly authorized by the resident as the resident’s general agent to execute the above and accept the items and with my signature so execute my permission.
I acknowledge the receipt of Forum’s Notice of Privacy Practices, Resident Rights and Medicare Supplier Standards included in the admission package. This notice relates to my medical and personal information and how it may be used, disclosed and accessed. I may view the Notice on Forum’s website at www.forumpharmacy.com. If I need another copy or have any questions related to the Pharmacy, I can call the pharmacy’s Privacy Officer at 847-673-8727.