Medication Management Intake Form

Address : 286 N Maple Grove Rd, Boise, ID 83704

Phone Number : (208) 287-4667

Please Fill Out The Fields Below With The Patients Information That Would Like To Start On Our Medication Management Program.

First Name *

Last Name *

Date of birth *

Sex *

Male

Female

Social Security Number *

Medicare Number

Phone *

Address *

Street Address

City

State

Postal code

Additional Patient Notes

Current Location Of Patient Care *

Home

Assisted Living

Independent Living

Is The Patient Currently On Hospice? *

Yes

Primary Provider Name *

Primary Provider Phone Number *

Medical Diagnosis

Allergies

Power Of Attorney Information

*The name of the facility at which the resident resides, or the name of the House Calls/Palliative Care program the patient is enrolled with. If none leave the Power Of Attorney section blank.

Click "NEXT" To Proceed

Next We Will Need Your Prescription Drug Insurance Information

Prescription Drug Insurance

It is very important for you to provide Mountain Care Pharmacy with the latest prescription insurance information to enable accurate billing. Most prescription insurance cards have the following information listed below:

Rx Group

Rx BIN Rx PCN Cardholder ID

Any cash paying customers or clients with prescriptions or supplements not covered by insurance will be automatically enrolled in our in house discount program. We do not bill outside discount programs. Contact Mountain Care Pharmacy for pricing inquiries.

Prescription Insurance Card

Yes, I Have One

No, I Do Not Have One

You MUST complete below information in order for Mountain Care Pharmacy to file your insurance claims.

Prescription Insurance Plan

Cardholder ID#

Rx Group#

Rx Bin#

Relationship To Cardholder

You MUST provide a copy of FRONT and BACK of the following items or we will not be able to process your insurance:

Insurance Card Or Medicare Card

Prescription Insurance Card (Front & Back Copied)

Medicare Card (Includes Medicare Part B or Parts A & B)

Upload Image Of Prescription Insurance Card Or Medicare Card

Click "NEXT" To Proceed

Lastly We Will Need You To Fill Out & Sign Our Pharmaceuticals Purchase Agreement

PHARMACEUTICALS PURCHASE AGREEMENT

This is an agreement for pharmacy services with Mountain Care Pharmacy

Patient Full Name *

And

Responsible Party Other Than Patient *

Please read, sign, and acknowledge the below financial agreement:

Financial Responsibility Agreement *

By checking the box and signing below, I acknowledge that I am financially responsible for all medications and services provided by Mountain Care Pharmacy. I understand that payment is due upon receipt of invoice unless prior arrangements have been made. I agree to pay all charges incurred for my (or my patients’) orders, including any costs not covered by insurance or third parties. I understand that failure to remit payment may result in collection action and additional fees as permitted by law.

Financial Responsibility Agreement Signature *

Clear

Signed Todays Date *

A valid debit/credit card is required to secure this account – kept on file

Type of Credit Card *

Visa

MasterCard

American Express

Discover

Name On Card *

Billing Address *

Credit Card Number *

Credit Card Expiration Date *

Credit Card CVC *

As a patient of Mountain Care Pharmacy, you acknowledge that you understand the following:

Beneficiary Full Name *

Beneficiary Date Of Birth *

Beneficiary Social Security Number *

AUTHORIZATION ASSIGNMENT OF BENEFITS AND INFORMATION RELEASE

I certify that the information I furnish is true and correct. I know it is a crime to fill out this form with facts that I know are false or to leave out facts that are important. I hereby authorize Mountain Care Pharmacy to submit a claim to my insurance carrier or its intermediaries for all covered prescriptions and direct my insurance carrier or its intermediaries to issue payment directly to Mountain Care Pharmacy. I hereby authorize Mountain Care Pharmacy to furnish complete information requested by my insurance carrier or its intermediaries regarding services rendered. I further agree that I am responsible for paying my co-pays or balances which remain after insurance payments have been made, including any cost of collection or legal fee incurred to collect these balances. I agree that Mountain Care Pharmacy may contact me in the future, via telephone or other means of communication, regarding ordering medical supplies.

ASSIGNMENT OF BENEFITS

I request that payment of authorized Medicare benefits be made to me or on my behalf to Mountain Care Pharmacy for prescription medications ordered by my physician. I authorize any holder of medical information about me to release to the Center for Medicare Medicaid Services and its agency any information needed to determine these benefits or the benefits payable for related services. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare assigned cases, the supplier agrees to accept the charge of determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered items. Coinsurance and the deductible are based upon the charge determination to the Medicare carrier.

Beneficiary Or Responsible Party Signature *

Clear

Beneficiary Signed Todays Date *

Responsible Party Printed Name Relationship to Beneficiary (If Beneficiary Unable To Sign)

This Form To Be Kept In Patient Record

I agree to terms & conditions provided by Mountain Care Pharmacy. By clicking this box, you provide express written consent to contact you via SMS, Phone, or Email as needed to converse with you. Standard messaging and data rates apply. Text STOP to opt-out at any time or unsubscribe.

Please Fill Out Our Medication Management

Intake Form Below

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