Parent/Guardian – Credit Card Authorization Form

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.

 

Student Name:  ________________________________________

School Attending:  _____________________________________

 

Signature of Guarantor:  _______________________________

Please Print Name:  _____________________________

Date:  ____________________________

 

 

Kent Station Pharmacy