Senior Living Enrollment Form

Senior Living Enrollment Form

Please complete all information and print clearly. Any missing information may cause a delay in receipt of services and supplies.
Resident Information
Community Name *
Community Acct. Number
This may be in a letter from your community.
Resident Name *

First Name Last Name
Sex *

Male Female
Date of Birth *

Month Day Year
SSN
Numbers only. No dashes.
Allergies
Physician/Prescriber *
Please provide the full Physician/Prescriber Name
Physician/Prescriber Telephone Number
Please enter a valid phone number.
Resident Insurance Information
Resident's Medication Insurance Plan *
Insurance Contact Phone *
Please enter a valid phone number.
Rx Insurance ID# *
Rx Insurance Group *
Rx Bin *
Rx PCN *
Page 1 of 2

Financially Responsible Party Information

(Please complete even if self)
Responsible Party Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Agreement to Pharmacy Services and Financial Responsibility

This agreement is entered into this day, between PharMerica (“Pharmacy”) and the Resident and Responsible Party listed above who agree as follows:
1. The Pharmacy shall provide pharmacy services and supplies to the Resident on an open account and will provide the Responsible Party a listing of the medications
supplied, and date of service.

2. The Resident and Responsible Party agree that they will be both individually and jointly responsible for paying to the Pharmacy any sums due for pharmacy services
and supplies furnished to the Resident that are not reimbursed by outside sources, and the Responsible Party hereby guarantees that the pharmacy will be paid all
sums due.

3. The Pharmacy will submit bills to the appropriate participating insurance plan or other reimbursement programs.

4. The Pharmacy will charge Resident or the Responsible Party for any co-payments and non-covered or un-reimbursed medications.

5. This Agreement shall bind the person or persons signed below. If signed by only the Responsible Party, it shall be binding on that party without regard to absence of
the Resident’s signature. If signed by only the Resident, the Resident shall be considered to be both the Resident and the Responsible Party for the purposes of this Agreement. Intending to be legally bound hereby, the Resident and Responsible Party have/has executed this Agreement providing for payment and guarantees of the sums due the Pharmacy for provision of pharmaceuticals and pharmacy services to the Resident on the date indicated below.

6. You consent to receive pharmacy services and supplies from PharMerica.
Responsible Party Authorization *

Yes! I authorize PharMerica to bill my account for pharmacy services. I may discontinue this agreement at any time by contacting the PharMerica Pharmacy. No: I choose to use another pharmacy provider. I understand this provider must comply with all applicable federal, state, and local laws and regulations pertaining to providing medications to a resident of a senior living community. This provider must have the capabilities of providing 24-hour and emergency service. EMERGENCY PROVIDER OPTION – While I choose to use another pharmacy provider as my primary provider, I authorize PharMerica Pharmacy to provide products or services to me in the event that my primary provider cannot provide services in a timely manner as determined by the community. I understand by choosing PharMerica as an emergency provider I agree with all terms and conditions listed above.
Resident or Responsible Party Signature *

Clear
If you have questions or need assistance, please email PharMerica at SeniorLiving.Enrollment@pharmerica.com

Page 2 of 2
Should be Empty:

Senior Living Enrollment Form

Resident Information

Resident Insurance Information

Financially Responsible Party Information

Agreement to Pharmacy Services and Financial Responsibility