PursueCareRx Pharmacy | Addiction Recovery Medication

Patient Enrollment Form

1Contact Information

2Insurance Information

3Medical History

4Waiver of Liability

Patient Contact Information

Patient Name(Required)

Patient SSN(Required)

Patient Date of Birth(Required)

Patient Email(Required)

Phone(Required)

Patient Address(Required)

Patient Medical History

Please select your birth gender(Required)

Male

Female

Allergies:

Are you pregnant?(Required)

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?(Required)

Yes

Patient's Full Name(Required)

Social Security Number:(Required)

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

Authorized Individuals Name(Required)

Authorized Individuals Phone Number(Required)

This request and authorization apply to (check all that apply):(Required)

Healthcare Information relating to the following therapy or condition.

All Healthcare Information

Please list the therapies and/or conditions the request is for:(Required)

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(Required)

I reside at:(Required)

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

Shipping Address:(Required)

Name of resident at shipping address:(Required)

Will the patient be signing for the package:(Required)

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.

Are you taking MAT medication (Buprenorphine)?(Required)

Yes

Patient contract terms for filling Buprenorphine prescriptions(Required)

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(Required)

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Questions?

Call the pharmacy on our toll-free number: 1-800-541-2030, or email us at info@pursuecarerx.com to send us a message.