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FIFTY 50 Pharmacy Patient Profile | |
Name_____________________________________ [ ] M [ ] F
Address_______________________________________________
City____________________ State_____ ZIP_______________
Shipping Address (if different than above)
______________________________________________________
Address_______________________________________________
City____________________ State_____ ZIP_______________
Phone(____)________________ Work(____)________________
Date of Birth (MM/DD/YY) _____/_____/_____
Social Security Number (SSN) _______-_____-_______
PHYSICIAN INFORMATION
Doctor's Name ________________________________________
Address_______________________________________________
City____________________ State_____ ZIP_______________
Phone(____)________________ Fax(____)________________
PRIMARY INSURANCE INFORMATION
Insurance Company Name________________________________
Address for Claims____________________________________
City____________________ State_____ ZIP_______________
Phone(____)________________ Fax(____)________________
Policy Holder's Full Name_____________________________
Relationship to Patient [ ] Self [ ] Spouse
[ ] Parent [ ] Guardian
Policy Holder's Date of Birth (MM/DD/YY)____/____/____
Policy Holder's SSN _______-_____-_______
Employer______________________________________________
Group Policy Number___________________________________
ID Number_____________________________________________
PRESCRIPTION DRUG CARD INFORMATION Card Name_____________________________________________ Plan #_______________________ Group #_________________ ID #__________________________________________________ PATIENT HISTORY Current Medications Taken_____________________________ ______________________________________________________ Known Drug Allergies__________________________________ ______________________________________________________ INSURANCE AUTHORIZATION AND ASSIGNMENT
I authorize Fifty 50 Pharmacy to submit claims on my behalf to my insurance company for any prescription drugs or medical supplies received by me or my dependents from Fifty 50 Pharmacy. I hereby assign all insurance benefits from such claims to Fifty 50 Pharmacy. If my insurance company or a third party payor pays any benefits directly to me, I agree to forward all monies received to Fifty 50 Pharmacy upon receipt of such monies. I understand that the filing of my insurance claims is provided as a courtesy to me and that in the event an item is not paid by my insurance company in full, I will be responsible for payment to Fifty 50 Pharmacy.
______________________________________________________ Signature of Patient ______________________________________________________ Signature of Policy Holder CREDIT CARD INFORMATION
You, the customer, are responsible for any co-payments and shipping. Fifty 50 will keep the credit card information provided below on file and use it for any such billings necessary to process your order(s). If you are on the Autoship program, your credit card will be automatically billed with each shipment.
Please bill any charges to the following account: [ ] MasterCard [ ] Visa [ ] American Express [ ] Discover Card No.______________________________________________ Name on Card__________________________________________ Signature_____________________________________________
Copyright © 1996 Juvenile Diabetes
Foundation International. ALL RIGHTS RESERVED.
The BETA SOCIETY, COUNTDOWN, CREATING A WORLD WITHOUT DIABETES,
THE DIABETES RESEARCH FOUNDATION, JDF, JUVENILE DIABETES
FOUNDATION INTERNATIONAL, THE ONLY REMEDY IS A CURE, WALK FOR THE
CURE, 1-800-JDF-CURE and 1-800-WALK-JDF are Trademarks and
Service marks of the Juvenile Diabetes Foundation International.
E-mail comments to info@jdfcure.com
Juvenile Diabetes Foundation
The Diabetes Research Foundation
120 Wall Street
New York, NY 10005-4001
800-JDF-CURE
212-785-9500
Fax 212-785-9595