We are thrilled you have chosen us to provide your loved one with their medications and other pharmacy needs throughout their stay at their new community! We want you to know that we are always here to help make your loved one’s transition into their community as smooth as possible. As part of our goal to ensure an easy process, we have two forms for you to complete and return to us:

FORM 1: Pharmacy Services, Financial Responsibility, and Payment Authorization Agreement.
The purpose of this form is to help us collect the correct billing information for your loved one. Therefore, we ask that you complete all requested information (including providing a copy of all insurance cards and providing the name and signature of the person who will be financially responsible for your loved one) to ensure that there are no problems when dispensing medications. We require that ACH be setup to begin and continue pharmacy services. You and your loved one will have the opportunity to review each bill before payment is automatically withdrawn from the provided bank account on the 25th of each month. This opportunity is made easy by giving you the ability to view your billing account online. To setup and access your account, please visit our website at http://www.themedexpharmacy.com and select “Online Payment Center.” To create a new account, you will need your unique Patient Code and the zip code that appears on your billing statement.

FORM 2: Authorization to Release Protected Health Information.
Our pharmacy will need this form to be completed before we can release your loved one’s protected health information to a Power of Attorney, or any other person(s) listed on the form. Your loved one’s express permission (or the express permission of a Healthcare Power of Attorney) is required by law before we can release any of your loved one’s protected health information. Please complete all requested information on the form, sign where indicated, and return the form back to us as soon as possible!

We kindly ask that you return these forms as soon as possible. If you have any questions or concerns regarding the forms, please call our Billing Department at (618) 515-4035 or (855) 700-7055.
We are incredibly grateful to you for choosing Medicine Express Pharmacy and for providing us with the necessary information to provide the best service possible to your loved one!

Warmest regards,
The Medicine Express Pharmacy Staff

PHARMACY SERVICES AND FINANCIAL RESPONSIBILITY AGREEMENT

PLEASE PROVIDE A COPY OF THE FRONT AND BACK SIDE OF THE INSURANCE CARD

1. Resident and Responsible Party unconditionally agree to pay the Pharmacy for all charges incurred as a result of the medications and other associated pharmaceutical products and services ordered by Resident’s physician or the administration and staff of the Community.
2. For Residents receiving benefits from an insurance company (referred as a “Pharmacy Benefits Manager” or “PBM”), Resident and Responsible Party are aware that the Pharmacy will bill the PBM for all medications, products and services covered by the PBM and that Resident or Responsible Party will be responsible for any co-payments that may apply and for the payment of all medications, products, and services provided by the Pharmacy that are not covered by the PBM.
3. Resident or Responsible Party will immediately notify the Pharmacy of any changes in the Resident’s insurance coverage or pay status and provide the Pharmacy with the Resident’s new insurance coverage information.
4. Resident and Responsible Party will notify the Pharmacy in writing at least 15 days prior to the next billing date of any changes in bank account information.
5. Payments must be made within 15 days of the billing statement date. Any billing statement over 30 days past due will bear interest at a rate equal to the maximum rate permitted by state law as of the due date of such billing statement and continuing until payment is made.
6. Resident and Responsible Party understand that if payment dates fall on a weekend or holiday, any payment may be processed on the next business day.
7. If a billing statement has not been paid within 60 days, the Pharmacy reserves the right to discontinue the provision of medications, products, or services to Resident.
8. If the Pharmacy is required to pursue legal action to collect any outstanding balance due, then Resident and Responsible Party agree to pay all costs of collection incurred by the Pharmacy, including, without limitation, reasonable attorneys’ fees and expenses actually incurred.
9. If Resident or Responsible Party disagrees with any medication, product, or service ordered by Resident’s physician or the administration and staff of the Community, then Resident or Responsible Party will contact them to resolve the issue or issues and ask them to provide new written orders to the Pharmacy. Resident and Responsible Party acknowledge and agree that the Pharmacy provides medications, products, and services based upon the most current written order received by it.
10. Resident and Responsible Party irrevocably consent to jurisdiction and venue in the Circuit Court of St. Louis County, Missouri in connection with any dispute arising out of or relating to this Agreement, and such Court will be the exclusive jurisdiction for litigation of any such dispute.

The undersigned certifies that they have read the above and that the information provided is complete and correct. By signing below, the undersigned accepts the terms and conditions contained in this Pharmacy Services and Financial Responsibility Agreement.

NOTICE: The Pharmacy may require documentation of the legal authority of the Resident’s Personal Representative (i.e., a Durable Power of Attorney for Health Care or a court order)

PAYMENT AUTHORIZATION FORM

I understand that by providing my bank account information, even if I do not authorize the recurring monthly charge described above, Medicine Express reserves the right to charge the bank account if and when a billing statement is overdue and delinquent. A billing statement will be deemed overdue and delinquent if no payment has been made within 30 days of such billing statement being sent to the patient.

No prior notification other than this agreement will be provided unless the date of payment changes, in which case Medicine Express will provide notice of such change at least 10 days prior to payment being collected. A receipt for each payment will be provided upon request.

NOTE: Insurance will be billed as the primary payer; your bank account will be charged for: (i) medications and other associated pharmaceutical products and services that are not covered by insurance, and (ii) copays (including deductibles and coverage gaps).

I authorize Medicine Express to charge the bank account indicated in this Payment Authorization Form according to the terms outlined above. I understand that this authorization will remain in effect until it is revoked in writing. I agree to notify Medicine Express in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this bank account and that I will not dispute the payment with my bank; provided the transactions correspond to the terms indicated in this authorization form.