Kent Station Pharmacy camp forms

38 North Main Street/Box 632 Kent, CT • (860) 927-3725 • Fax: (860) 927-3895 • campinfo@kentstationpharmacy.com

Camper Registration

Parent/Guardian Name:

First Name

Last Name

Parent/Guardian Email:

Home Phone:

Cell Phone:

Camper Name

First Name

Last Name

Gender

Male

Female

Date of Birth:

dd-MMM-yyyy

Address

Street Address

Address Line 2

City

State/Region/Province

Postal / Zip Code

Country

Allergies and Misc. Information

Drug Allergies? (please list)

Food Allergies? (please list)

Other Allergies? (please list)

Anything else we should know?

Prescription Insurance Information

Camper Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Rx Member ID:

Rx BIN Number:

RX PCN Number

Rx PCN Number:

Rx Group:

Parent/Guardian or Insured Street Address:

Street Address

Address Line 2

City

State/Region/Province

Postal / Zip Code

Country

Credit Card Authorization

Card Type (select one):

Visa

MasterCard

AMEX

Discover

Card Number

Exp. Date

MMM-yyyy

Security Code

Name on Card

First Name

Last Name

Billing Address

Street Address

Address Line 2

City

State/Region/Province

Postal / Zip Code

Country

Terms and Conditions

I acknowledge and assume responsibility and grant authorization for Kent Station Pharmacy to charge the above credit card for registration and sign-up fees where applicable. I also acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication that Kent Station Pharmacy cannot get reimbursement for, as well as any co-insurance and deductibles and charges for requested OTC products which l agree will be billed to my credit card by Kent Station Pharmacy. I authorize Kent Station Pharmacy to contact my insurance company for insurance verification, billing, and collections for my medications. As per our HIPPA agreement all personal information received will be solely maintained for the purposes of dispensing prescriptions and insurance collection. I understand that I am responsible for the costs of all medication changes received after a prescription has been filled or packaged.

I accept the Terms and Conditions.

Camper Name

First Name

Last Name

Signature of Guarantor:

Please Print Name:

Date:

dd-MMM-yyyy

Notice of Privacy Practices

Terms and Conditions

Parents/Guardians: Please sign the following form after reviewing Kent Station Pharmacy’s Notice of Privacy practices, which can be found at www.kentstationpharmacy.com. Kent Station Pharmacy is covered by the medical information privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (generally called “HIPAA”) and its Regulations. As a result, we are required to comply with HIPAA and the Regulations in the use and disclosure of health information by which our patients can be individually identified. We are also required under Section 164.520 to give our patients this notice (in paper or electronically as the patient wishes) of our legal duties and privacy practices concerning their Protected Health Information, and also to tell our patients about their rights under HIPAA and the Regulations. If you have any questions about our policies, please contact us directly. We are required by this Act to request your signature upon receipt of this document. Please sign your first and last name clearly on the line below. If your child is 18 or older, he or she may sign as an adult. I have reviewed a copy of the Kent Station Pharmacy Privacy Notice

I accept the Terms and Conditions.

Signature

Camper Name

First Name

Last Name

Date:

dd-MMM-yyyy