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New Patient Form
1030 Avenue D, Suite 2, Snohomish, WA 98290
(P) 360-863-3009 (F) 360-217-7570
www.matrxltc.com
EMERGENCY FILL ONLY
ROUTINE MEDICATION SERVICE
OK TO BILL OTC (non-covered)
up to $
New Patient Information
Patient Name
*
Gender
*
MALE
FEMALE
DOB
*
Home Name/Location
*
Room or Unit #
Prescription Insurance
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*
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Input Information
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Type
*
Medicare
Medicaid
Other
Soc. Sec. #
*
Insurance Name
Contract (ID#)
BIN#
PCN
RX Group
Primary Physician Name
Specialist Name
Responsible Party for Billing Information
Name
*
Relationship
*
Address
*
City
*
State
*
Zip Code
*
Phone # (not facility):
Please provide an email for Electronic Billing Statements
*
I agree that I am responsible for all pharmacy charges for the above resident which are not covered by private insurance or Medicaid. I agree to pay statement balances on receipt unless other arrangements are made. Late payments of 30 days or longer will bear interest at rate of 12% per annum.
I agree to allow staff at the facility to act as my agent in both ordering and receiving medications.
I acknowledge that I have received a copy of the notice of privacy practices.
I request that my prescriptions be packaged in standard containers
without
child resistant safety caps.
A credit card or voided check is
required
, and will be charged if no payment(s) or arrangement(s) for payment have been made for charges 30 days past due.
ACH or Credit Card
*
ACH
Credit Card
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Account Number
Routing Number
Name on Card
*
Card Type
*
Visa
MasterCard
American Express
Discover
Card Number
*
Expiration Date
*
Billing Zip Code
*
Signature
*
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Date
Signature
*
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Date
I accept the legal terms and conditions
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Time signed:
IP address submitted:
