Application For Services & Responsible Party Authorization printable pdf download

& R

PPLICATION FOR

ERVICES

ESPONSIBLE

ARTY

UTHORIZATION

Please complete, sign and return this original for Universal Medication Management

To expedite order please fax to 866-268-8262

ATIENT

NFORMATION

**Medications are sent to the address below on a monthly basis**

Last Name: ____________________________________ First Name: _________________________________ Middle Initial __________________

M / F

Social Security #_______________________________________________

Gender:

Date of Birth_____________________________

Telephone: (I) (______) ______________________ (II) (_________) ____________________ Contact person_______________________________

Address: ________________________________________________________________________________________________________________

City _____________________________________ State _________ Zip _______________ Allergies: _____________________________________

Yes  No

Do you speak and read English?

If no, what is your primary language:________________________________________

Referred to UMM by:

Primary MD: ______________________________________ Phone: ___________________________

Attending MD: ____________________________________ Phone: ____________________________

______________________________

Specialist MD: ____________________________________ Phone: ____________________________

LERTS

Telephone #s for Alerts

Does the patient have Wi-Fi Access? Yes  No

(I)

(________)_______________________(required)

(II)

(________)_______________________(optional)

(Wi-Fi is required for text or e-mail alerts)

NSURANCE

NFORMATION

*** Please complete and attach a copy of the patient’s identification and Insurance/Medicare Part D card (both front and back)***

Medicare / Medicaid Number ______________________________ Part D Prescription Plan Name________________________________________

Group #_______________________________ Bin #______________________ Pcn # ______________________ ID # ______________________

(_) Private Health Insurance Company (Workers Comp) _________________________________________________________________________

Member ID # _________________________________________ Phone Number of Insurance Co ________________________________________

ESPONSIBLE

ARTY

NFORMATION

***Please note, the person named as the responsible party must be the same person that signs this form.***

(_) I am my own Responsible Party (RP). OR

Last Name: ________________________________ First Name: __________________________ Relationship to Patient ______________________

Address: _____________________________________________________City _____________________________ State _______ Zip __________

Telephone: (I)__________________________________(# for alerts Y / N ) (II) ______________________________________________________

Invoices are sent to the address above on a monthly basis.

Credit Card Number (for Co-Pays only)_______________________________________ EXP _______________ Authorization code ___________

Assignment of benefits: I hereby authorize Universal Medication Management contracted pharmacies to receive any payments from my insurance company

for prescription medications and or medical supplies. Pharmacy Policy: To ensure efficient monitoring and dispensing of medications, our program uses the UMM Pill

Box. Any cost associated with this process described above will be billed directly to the responsible party’s insurance, as indicated above. Co-pays will be billed to the

patient from the UMM contracted pharmacy, and it remains the patient’s responsibility to pay the insurance mandated co-pays.

The UMM Pill Box is hereby leased to the patient at no cost as long as the patient is actively using the UMM service (“on-service”). Upon termination of the UMM

service, the UMM Pill Box is to be returned to Universal Medication Management, or the Responsible Party/beneficiaries become responsible for the cost of retrieving

the UMM Pill Box, and all associated collection costs. Contact UMM at the number below or send the box to the address below.

I have read and understand the medication policy as described above. I realize that all costs incurred with this policy are my responsibility and I agree to make payment

in full as outlined. I acknowledge that I have received, read and understand the attached written copy for the Notice of Private Practices for Universal

Medication Management.

Responsible Party Signature _____________________________________________

Date _________________

Universal Medication Management

315 S. Beverly Dr. Suite 310, Beverly Hills, CA 90212 / Phone: (800) 626-0563 Fax: 866-268-8262