brand
Guardian Pharmacy of Michigan
2930 29th St SE, Grand Rapids, MI 49512
(616) 965-7480
https://guardianpharmacymichigan.com/
PHARMACY SERVICES & PURCHASE AGREEMENT
between Guardian Pharmacy of Michigan, LLC and
Resident Information & Prescription Drug Insurance
Resident Gender
Contact Information
Clear signature
brand
Please review the following statements.

  • The Resident/Responsible Party agrees to pay for any purchases made from Guardian Pharmacy, either directly or by facility personnel on the Resident's behalf, and agrees to pay the full invoice amount by the invoice due date.

  • Resident/Responsible Party agrees that Guardian Pharmacy will bill the credit card or banking information listed below if payment is not received by the invoice due date.

  • Resident/Responsible Party understands and agrees that Guardian Pharmacy will discontinue service if payment is past due and may send to collections and/or report to credit reporting agencies. A finance charge of 1.5% per month may be charged on balances over 30 days past due.

  • Some commercial insurance plans do not cover Long Term Care (LTC) Services. If your plan does not cover these services, Resident/Responsible Party agrees to pay the fee for LTC services received that may be reflected on your invoice.

  • Resident/Responsible Party understands that the use of Guardian Pharmacy as a provider of pharmaceuticals and other related services is optional.

  • I consent to allow Guardian Pharmacy, its agents, and assignees to contact me by email, phone, and SMS message communication using any contact information that I have provided to Guardian Pharmacy, the physician or facility, for purposes related to my care including treatment, insurance benefits, payment, collections, or operations.

Notice of Privacy Practices & Patient Bill of Rights

I certify that I have had an opportunity to review Guardian's Privacy Notice at the below listed internet link and ask questions to assist me in understanding the rights relative to the protection of the above-named person's health information. https://guardianpharmacy.com/hipaa-privacy-policy/

I certify that I have had an opportunity to review Guardian's Patient Bill of Rights at the below listed internet link and ask questions to assist me in understanding the rights relative to the protection of the above-named person's health information. https://guardianpharmacy.com/bill-of-patient-rights/

Pharmacy Services Opt-Out
Your community has chosen Guardian Pharmacy as its preferred pharmacy because of the outstanding level of care and service we provide to our residents. However, the Centers for Medicare and Medicaid Services (CMS) guarantees a beneficiary his or her right to a choice of pharmacy providers. We sincerely hope you choose Guardian Pharmacy as your provider, but we will honor your choice if you prefer another provider.

I understand that opting out means missing routine, scheduled deliveries right to the community, 24/7 pharmacy service, safe medication packaging that ensures timely and accurate medication administration, and cost savings opportunities.

Clear signature
brand
Guardian Pharmacy of Michigan
2930 29th St SE, Grand Rapids, MI 49512
(616) 965-7480
https://guardianpharmacymichigan.com/
Please fill out one of the boxes below to provide Banking (preferred) or Credit Card Information.

Enter payment info below or click submit if finished.

Banking Information or Credit Card is required:

Banking Information (Preferred):

OR

Type of Card:

Please select a payment option below.

Please initial to acknowledge the above

/