Secure Form

Enter your credit card payment info

Type of Card:

Cardholder Name

Billing Address

Card #

Expiration

Security Code

Payment Options and Authorization

Please select one of the following payment options:

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

Manual Payment Submission: I will manually submit monthly payments by the invoice due date and authorize Lo Cost Pharmacy to bill the payment method provided if payment is not received by the invoice due date.

Acknowledgment of Payment Terms

Please review the following statements:

Resident/Responsible Party agrees to pay for any purchases made from Lo Cost Pharmacy either directly or by facility personnel on Resident's behalf and agrees to pay the full invoice amount by the invoice due date.
Resident/Responsible Party agrees that Lo Cost Pharmacy may bill the credit card listed above if payment is not received by the invoice due date.
Resident/Responsible Party understands and agrees that Lo Cost Pharmacy will discontinue service if payment is past due and may send the account 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, the Resident/Responsible Party agrees to pay the fee for LTC services received that may be reflected on your invoice.
Resident/Responsible Party understands and agrees that Lo Cost 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.

By signing below, I authorize Lo Cost Pharmacy to charge my credit card.

Cardholder’s Name:

Cardholder’s Signature:

( - ) show alternative signature box

Date: