* If payment is not received from resident within 60 days, Guardian will attempt to contact the responsible party. After which, if payment still has not been received, payment will be drafted from card on file. Credit card will only be used after Guardian notifies responsible party of non-payment of an outstanding balance. Guardian reserves the right to withhold services if payment is 90 days or more past due and no good faith effort has been made to bring the balance current. Payments that remain delinquent may be turned over to collections and reported to credit reporting agencies.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

In exchange for Guardian Pharmacy of Birmingham’s agreement to provide me with medications, I agree to the following terms and conditions:

1. AUTHORIZATION FOR MEDICAL TREATMENT. I authorize Guardian Pharmacy of Birmingham, at the direction of my physician, to provide medications to me. I certify that no guarantee or promise, express or implied, has been made to me in conjunction with the medications that have been prescribed for me.
2. MEDICAL RESPONSIBILITY. I understand that I am under the supervision and control of my attending physician and that my physician has prescribed the medication therapy that is being supplied by Guardian Pharmacy of Birmingham. Guardian Pharmacy of Birmingham does not provide diagnostics, prescriptions, products, or other functions unless otherwise authorized in writing by a physician. Accordingly, I understand that it is solely the responsibility of my physician to advise me on prescription medications and therapies, including why they are part of my treatment and how they may impact my condition.
3. FACILITY INVOLVEMENT. I understand and agree that in order to provide me with the best treatment possible, Guardian Pharmacy of Birmingham may share health information related to my medical condition, treatment, medication regimen, etc. with my long-term care facility or any of my treating physician. In recognition of this need, I authorize Guardian Pharmacy of Birmingham to share any necessary patient health information related to me with my facility or physician. I also authorize facility personnel to purchase medications, or other health care products that I may need, on my behalf.
4. FINANCIAL RESPONSIBILITY. In consideration of Guardian Pharmacy of Birmingham supplying me with physician-requested products or services, I agree and accept responsibility for the payment of all sums that may become due for medications provided to me by Guardian Pharmacy of Birmingham. If, for any reason, Guardian Pharmacy of Birmingham does not receive payment from my insurer or a third-party payor that is obligated to pay for my medications, I do hereby agree to pay Guardian Pharmacy of Birmingham directly for the unpaid balance within thirty (30) days of each monthly statement date. A credit card may be required to secure your account.
5. PAYMENT OF BENEFITS. I authorize Guardian Pharmacy of Birmingham to submit a claim(s) to my insurance carrier or a third-party payor that is obligated to pay for all covered prescriptions or durable medical equipment. I further direct my insurance carrier or third-party payor to issue any payments directly to Guardian Pharmacy of Birmingham.
6. ASSIGNMENT OF BENEFITS. I authorize Guardian Pharmacy of Birmingham to request and collect on my behalf all public and private benefits due for the products and services supplied by Guardian Pharmacy of Birmingham. In the event any payments are made directly to me, I agree to promptly endorse and forward such payment to Guardian Pharmacy of Birmingham.
7. UNPAID INVOICES. Guardian Pharmacy of Birmingham encourages residents to keep their accounts in good standing. However, if my account becomes past due, I agree that any amounts outstanding for more than thirty (30) calendar days shall bear interest from the due date of such invoice, at the lesser of one and a half percent (1.5%) per month or the maximum rate permitted by applicable law. I further agree to pay all costs or expenses incurred by Guardian Pharmacy of Birmingham related to collection efforts, including reasonable attorneys’ fees and court costs.
8. WITHHOLD SERVICES. Guardian Pharmacy of Birmingham reserves the right to discontinue services to my account if I have not paid the account in full within 60 days. Payments that remain delinquent may be turned over to collections.
9. RELEASE OF INFORMATION. I authorize any insurer or third-party payor who provides me with coverage to disclose to Guardian Pharmacy of Birmingham any information regarding such coverage, including but not limited to the scope and extent of coverage available, as well as information related to any payments made on my behalf for services rendered by Guardian Pharmacy of Birmingham. I also authorize all medical personnel to disclose information to Guardian Pharmacy of Birmingham relating to my medical history as it related to pharmacy services or therapy.
10. HIPAA AUTHORIZATION. I give permission to Guardian Pharmacy of Birmingham to use or disclose certain aspects of my health information to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies.

I UNDERSTAND AND HAVE REVIEWED THE NOTICE OF PRIVACY PRACTICES, THE NOTICE OF NONDISCRIMINATION AND COMPLAINT PROCEDURES, INJURY, INFECTION AND EMERGENCY PREPAREDNESS, AND THE PAYMENT INFORMATION DOCUMENTS AND AGREE TO BE BOUND BY THEM.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.