LTC/Blister Pack Intake

LTC/Blister Pack Intake
Program
1. Current living situation?*

Home or Medical at HomeGroup Home

Patient's Information
2. Name*

First NameLast Name
3. Date of Birth*

MonthDayYear
Date
4. Phone Number *
Please enter a valid phone number.
Do you have an email?*

YesN/A
5. Email*
example@example.com
6. The name of a contact (if not self)

First NameLast Name
7. Contact's Phone Number
Please enter a valid phone number.
8. Contact's Email
example@example.com

Medication List
9. Drug allergies?

YesNo
9a. If yes, please list them:
10. Daily Medications that you request to be in Blister Packs (USE FORMAT: Medication name/DOSAGE/FREQUENCY)*
11. If you have a list of medications, please upload here:

Cancelof
12. As needed medications:*
Primary Care Doctor
13. Name*

First NameLast Name
14. Phone Number*
Please enter a valid phone number.
15. Fax #*
Please enter a valid phone number.
Question
16. Do your medications change every (1, 2, or 3) months?*

Yes, give me a single blister packNo, give me monthly blister packOther:
16a. If you chose other, please specify:*

Signature:
FINANCIAL AGREEMENT
(1)Your insurance company requires a Co-payment/ Coinsurance to be paid when you seek certain medical
services. In turn, we are contractually obligated to collect any deductible, co-payment, or coinsurance
from our patients.
(2)I acknowledge that my insurance company and I have an agreement and I am responsible for the payment
of any co-payment, coinsurance, or deductible for health services provided to me, or my dependent.
I promise and attest that I will pay the required deductible, co-payment, or coinsurance to Esco Drug Co In. within thirty (30) business days from receiving a bill. Patient statements are mailed when explanation of benefits are received from your insurance company, including co-payments.

(3) I am agreeing to provide up to date medication therapy with the pharmacy whenever there is a change (ie in medications, dosages or patient status (if patients have been admitted to hospitals or rehab, changes in residence). I agree to enroll into the 30 days Blister pack program. Failure to update will result in termination from the Blister pack program. The pharmacy reserves the right to provide blister pack to eligible member. Furthermore, I am agreeing to Esco Pharmacy’s terms and conditions.( link https://www.escopharmacy.nyc/policies/terms-of-service )
17. Please sign this form:*

Clear
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