Pharmacy Patient Enrollment Form

Please fill out the questions below. Items with a * require a response.

1Contact Information

2Insurance Information

3Medical History

4Waiver of Liability

Patient Contact Information
Patient Name*
First Last
Patient SSN*
Patient Date of Birth*
MM slash DD slash YYYY
- Patient Email*
- Phone*
Patient Address*
Street Address City State ZIP Code

Patient Medical History
Please select your birth gender*
- Male
- Female
Allergies:
Check below if there are no known allergies
No known Allergies
Are you pregnant?*
Medical/Healthcare Information Authorization: HIPAA
- Do you need to authorize PursueCareRx Pharmacy to release or discuss medical related healthcare issues or allow medication pickup for other people?*
  - Yes
  - No
- Patient's Full Name*
  First Last
- Social Security Number:*
I request and authorize PursueCareRx Pharmacy to release, discuss medical related healthcare issues or pickup my medication to the below listed:
- Authorized Individuals Name*
- Authorized Individuals Phone Number*
- This request and authorization apply to (check all that apply):*
  - Healthcare Information relating to the following therapy or condition.
  - All Healthcare Information
- Please list the therapies and/or conditions the request is for:*
Consent revocation acceptance.*
By checking this box I agree to and understand the statement about revoking consent below.
I understand that I may revoke this consent at any time, and that upon fulfillment of the above stated purpose or lapse of twelve months from the date of the signature, whichever comes first, this consent will automatically expire without my express revocation, but that revocation may not be applied retroactively once the information has been released in good faith. I do not authorize further release to any other third party. I understand that PURSUECARERX PHARMACY, and its staff, employees and directors cannot be responsible for confidentiality of information disclosed after said information has been released pursuant to this responsibility or liability that may arise from this authorization.

We ask that you fill this out during enrollment in the event you decide to have medication shipped to you either immediately or in the future.

Release and Waiver of Liability, Assumption of Risk, and Indemnity

READ THIS RELEASE CAREFULLY BEFORE SIGNING IT. YOUR SIGNATURE INDICATES YOU UNDERSTAND IT AND AGREE ON ITS TERMS. BY SIGNING THIS RELEASE, YOU ARE GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE OR RECOVER DAMAGES IN CASE OF LOSS OF MEDICATION OR FAILURE TO RECEIVE MEDICATION, FOR ANY REASON.

The undersigned, residing at the address below, acknowledges this Release on behalf of themself.
- Patient Name*
  First Last
I reside at:*
Street Address City State ZIP Code
I HEREBY:

1. Acknowledge that I have given permission to PursueCareRx to ship my medication package to the address located below;

2. Acknowledge that I have permission from the resident of the address to ship my medication there for receipt by me;

3. Voluntarily assume the risk and potential loss of said package, should I not receive it upon or after delivery;

4. Release, discharge, indemnify, and otherwise promise not to sue Pharmacy Associates, Inc. dba PursueCareRx and/or any of its owners, officers, employees, agents or affiliated entities (hereinafter the “Releasees”), for any loss, liability, damages, or cost whatsoever arising out of or related to any loss, damage, or injury I experience as a result of shipping my medication;

5. Release the Releasees from any claim that such Releasees are or may be negligent in connection with my medication shipment;

6. Expressly agree that this Release is governed by the State of West Virginia and is intended to be as broad and inclusive as is permitted by West Virginia law, and that in the event any portion of this Release is determined to be invalid, illegal, or unenforceable, the validity, legality and enforceability of the balance of the Release shall not be affected or impaired in any way and shall continue in full legal force and effect;

7. Acknowledge that this Release forms a contract and agree that if a lawsuit is filed against PursueCareRx or the Releasees for any reason in breach of this contract, I will pay all attorney’s fees and costs incurred in defending such an action;

8. Am eighteen (18) years of age or older.
Ship to patient at patient's address
- Ship to patient at patient’s address
Shipping Address:*
Street Address City State ZIP Code
- Name of resident at shipping address:*
  First Last
- Will the patient be signing for the package:*
I understand that PursueCareRx will verify that I have permission to ship to the above address and will ask the recipient signer for certain identifying information about me to verify their relationship with me, and ability to accept medication shipment on my behalf. I understand that this must be verified and completed prior to my next shipment. If this information is not verified it may delay my shipment.
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PursueCareRx Notice of Privacy Practices
By checking this box I agree to and understand the PursueCareRx Notice of Privacy Practices
Your health information is contained in a medical record that is the physical property of Pharmacy Associates, Inc. dba PursueCareRx. Pharmacy Associates, Inc, dba PursueCareRx uses health information about you for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive. Under federal HIPAA regulations, you and Pharmacy Associates, Inc. dba PursueCareRx have certain rights and restrictions relating to the uses and disclosure of your information. Among its obligations, Pharmacy Associates, Inc. dba PursueCareRx is required to maintain the privacy of protected health information; provide you notice of its legal duties and privacy practices; notify you if we are unable to agree to a requested restriction on how your information is used or disclosed; accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and obtain your written authorization to use or disclose your health information for certain defined reasons. THE FULL TEXT OF PHARAMCY ASSOCIATES, INC DBA PURSUECARERX’S PRIVACY NOTICE HAS BEEN PROVIDED TO YOU ALONG WITH OTHER NEW PATIENT INFORMATION, THE NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY.
Are you taking MAT medication (Buprenorphine)?*
- Yes
- No
Patient contract terms for filling Buprenorphine prescriptions*
By checking this box I agree to accept the following patient contract terms for filling buprenorphine prescriptions, if/when applicable, with PursueCareRx Pharmacy (examples: Subutex, Suboxone, Buprenorphine/Naloxone, etc.):
1. I will keep my medication in a safe and secure place away from children (e.g., in a lock box or locked cabinet). I understand that the medication is my responsibility, and that I must take full responsibility for accounting for my medication at all times.

2. I will take the medication exactly as my doctor prescribes. If I want to change my medication dose, I will speak with the doctor first. Taking more than my doctor prescribes is medication misuse. My doctor will be notified by the pharmacy if I am suspected of misusing my medication. Prescriptions for quantities outside of typical treatment guidelines will not be filled.

3. I understand that I cannot take certain other medications such as benzodiazepines (drugs like Valium®, Klonopin® and Xanax®), alcohol or other opioid medications as this may result in serious/life-threatening side effects.

4. I understand that I may not obtain buprenorphine or other opioid prescriptions from multiple doctors or fill my prescriptions with multiple pharmacies. I understand that “new” prescriptions are not to be filled “early,” except when authorized by prescriber in emergency situations.

5. I understand that it is illegal to give away or sell my medication – this is diversion. If I do this, I understand that my prescription may no longer be filled at PursueCareRx Pharmacy and will be reported to my doctor and the authorities.

6. I understand that I must submit to drug testing as instructed by my doctor and will comply with my doctor’s treatment plan and testing as necessary. I understand that I may be required to attend therapy/counseling as part of my doctor’s treatment plan and will do so according to my doctor’s instruction.

7. I understand that I must provide the pharmacy with a form of government issued photo identification for drop-off/pick-up of all new and refilled prescriptions, as required by state and federal regulations. I understand that I must provide my current prescription insurance information to the pharmacy.

8. I understand that I should drop off and pick up my own prescription (no representatives).

9. I understand that I should bring my current labeled buprenorphine-based medication prescription container, whether containing remaining medication or empty, with me every time I come to the pharmacy to pick up a new or refill prescription for a buprenorphine-based medication.

10. I understand that I must NEVER use inappropriate language or inappropriate behavior, either while in the pharmacy or on a phone call. I understand these actions may result in my immediate dismissal from pharmacy services.

11. I understand that I will not take any illegal substances or any medication not prescribed to me and/or monitored by my pharmacist.
I have read this entire Release. I understand, acknowledge, and consent to its terms by signing below:
Today's Date*
MM slash DD slash YYYY
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Pharmacy Patient Enrollment Form

Patient Contact Information

Patient Insurance Information

Patient Medical History

Medical/Healthcare Information Authorization: HIPAA

I request and authorize PursueCareRx Pharmacy to release, discuss medical related healthcare issues or pickup my medication to the below listed:

Release and Waiver of Liability, Assumption of Risk, and Indemnity