Agreement to Participate in SyncRx,
Bremo’s Synchronized Prescription Refill Service

Thank you for your interest in the SyncRx at Bremo Pharmacy.

Advantages of participating in the program include:

• Increased convenience—a single monthly trip to the pharmacy or FREE delivery
• Peace of mind from being able to get medications on time and in one order
• More personal contact with your pharmacist to ask questions and discuss medications
• Increased understanding of your medication, its purpose, potential side effects and costs.
• Your prescription records can be more easily updated to reflect changes in therapy made by doctors or upon hospital discharge.
• Pocket Medication lists available
• Benefits offered: waived packaging fees, waived delivery fees, waived medication disposal fee.

I understand the program’s advantages and the following conditions of participation to achieve the maximum benefits from the service. I hereby agree:

• To pick up medications or accept a delivery on my assigned refill date.
• To keep an open dialogue with my pharmacist regarding doctor’s appointments, hospital/urgent care visits, and changes in my health status, or address.
• To inform the pharmacy of any changes in contact information or address.
• If necessary, to pay an extra co­pay one time for each medication in order to make all refills due on the same day.
• To have a credit card on file as payment for prescription copays and OTC purchases.
• To accept a monthly phone call from pharmacist to discuss prescription refills.

I request that payment of authorized Medicare or other Health Insurance Payer benefits be made either to me or on my behalf for any services furnished me by or in Richmond Apothecaries, Inc. Pharmacies (Bremo or Bremo LTC) including physician services.  I authorize any holder of medical or other information about me to release to the Health Care Financing Administration or other Health Insurance Payer and its agents any information needed to determine these benefits or for related services. I recognize that in the event that the insurance carrier does not pay for this service or reimbursement is sent to me rather than to the pharmacy, I am responsible for payment.