Secure Form

Social Security Number

Date of Birth

Community/Facility Name

Medicare ID #

Primary Care Physician

Physician Phone

Gender

MALE

FEMALE

Prescription Insurance Plan

Cardholder ID #

RX Group #

RX BIN #

PCN #

Relationship to Cardholder:

SELF

SPOUSE

OTHER

Please list the resident’s allergies (click “+” to add additional lines)

No allergies

A photocopy of the insurance card (front and back) is optional to be included for the pharmacy to process insurance.

Photo of the card front side:

Photo of the card back side:

Responsible Party for Payment & Primary Contact Person - your statement will be mailed to this address:

Responsible Party Full Name

Phone

Email

Street

City

State

Zip

Please fill out one of the boxes below to provide Credit Card or Banking Information. The following information may be provided by completing the form below, uploading a copy of the front and back of your credit card, or by contacting the billing department at (616) 965-7480 to provide this information verbally.

Photo of the card front side:

Photo of the card back side:

Elected to contact pharmacy by phone

Type of Card:

Cardholder Name

Billing Address

Card #

Expiration

Security Code

Banking Information:

Bank Name

Bank Routing Number

Bank Account Number

Name on Account

Please select one of the following payment options:

I want to enroll in automatic payment processing using the information provided above and I authorize Guardian Pharmacy to collect payment for charges not paid by my insurance company. Automatic payments will be processed based on the invoice due date.

I will manually submit monthly payments by the invoice due date and authorize Guardian Pharmacy to bill the payment method provided if payment is not received by the invoice due date.

Resident or Responsible Party Signature:

Please review the following statements.

Resident/Responsible Party agrees to pay for any purchases made from Guardian Pharmacy either directly or by facility personnel on Resident's behalf and agree to pay the full invoice amount by invoice due date.
Resident/Responsible Party agrees that Guardian Pharmacy may bill the credit card or banking information listed above 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.
Resident/Responsible Party understands and agrees that Guardian Pharmacy may, at the phone number provided above, make automated phone calls and send SMS text messages and other types of automated messages and reminders regarding billing and payment for Guardian Pharmacy's services.

Please initial to acknowledge the above

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

I accept the legal terms and conditions

Resident or Responsible Party Signature:

( - ) show alternative signature box

Date

Guardian Pharmacy of Michigan

2930 29th St SE, Grand Rapids, MI 49512

(616) 965-7480

https://guardianpharmacymichigan.com/

Welcome Letter Reviewed

PHARMACY SERVICES & PURCHASE AGREEMENT

Resident Information & Prescription Drug Insurance

Guardian Pharmacy of Michigan

2930 29th St SE, Grand Rapids, MI 49512

(616) 965-7480

https://guardianpharmacymichigan.com/

Responsible Party for Payment & Primary Contact Person - your statement will be mailed to this address:

Please select one of the following payment options:

Guardian Pharmacy of Michigan

2930 29th St SE, Grand Rapids, MI 49512

(616) 965-7480

https://guardianpharmacymichigan.com/

Please review the following statements.

Please initial to acknowledge the above

Notice of Privacy Practices & Patient Bill of Rights