Forms

Please fill out the Pharmacy Admission Form and submit it.

Responsible Party Personal Information

Full Name:

DOB:

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

What is your preferred method of contact? PHONE / EMAIL (include both)

Phone Email (Include both)

Phone #

Patient Personal Information

Full Name:

DOB:

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Social Security#

Billing Information (Please attach a photo copy of your prescription insurance card)

Prescription Insurance Provider

RX BIN

PCN

GROUP #

ID #

Method of Payment (Select one and provide the additional info necessary to process payment)

Credit card *PREFFERED Is this an International credit card? YES / NO If yes,

please list country:

Card number

Expiration

CVV

Personal Check (attach a voided check) E-check/ Wire

Account #

Routing #

Disclaimer and Signature

By signing below: I understand that all requested information is required in order for Synergy Pharmacy to provide services. I understand if insurance information is not provided Synergy Pharmacy will bill the responsible party directly. I understand the responsible party is liable for all medication charges during the patients stay at Caron Treatment Center. I authorize Synergy Pharmacy to provide medications to the patient listed above during their stay at Caron Treatment Center. I authorize Synergy Pharmacy to bill the provided method of payment for services rendered not to exceed five hundred dollars without authorization. I certify that I am an authorized user of this credit card /bank account and will not dispute these transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated above

Signature:

Date: