Student Registration Form Parent/Student InformationParent/Guardian Name: Parent/Guardian Email: Home Phone:Cell Phone:Student’s Name: GenderMaleFemaleDate of Birth: MM slash DD slash YYYY Street Address: City: State: Zip: School Name: Allergies and Misc. InformationDrug Allergies? (please list)Food Allergies? (please list)Other Allergies? (please list)Anything else we should know?Prescription Insurance InformationStudent Name: School Name: Parent/Guardian or Insured Name: Rx Member ID: Rx BIN Number: Rx PCN Number: Rx Group: Parent/Guardian or Insured Street Address: City: State: Zip: REMEMBER: It is critical to forward us a copy of both sides of the insurance card of the parent/guardian and the patient. We are always available to answer any questions you may have at (860) 927-3725.Parent/Guardian Credit Card InformationCard Type:VisaMasterCardAMEXDiscoverCard Number: Exp. Date: Security Code: Name on Card: Billing Street Address: City: State: Zip: 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: Name of Guarantor: Date MM slash DD slash YYYY Notice of Privacy PracticesParents/Guardians: Please sign the following form after reviewing Kent Station Pharmacy’s Notice of Privacy practices, which can be found at www.kentstationpharmacy.com. Kent Station Pharmacy is covered by the medical information privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (generally called “HIPAA”) and its Regulations. As a result, we are required to comply with HIPAA and the Regulations in the use and disclosure of health information by which our patients can be individually identified. We are also required under Section 164.520 to give our patients this notice (in paper or electronically as the patient wishes) of our legal duties and privacy practices concerning their Protected Health Information, and also to tell our patients about their rights under HIPAA and the Regulations. If you have any questions about our policies, please contact us directly. We are required by this Act to request your signature upon receipt of this document. Please sign your first and last name clearly on the line below. If your child is 18 or older, he or she may sign as an adult.I have reviewed a copy of the Kent Station Pharmacy Privacy Notice.Full Name Date MM slash DD slash YYYY I authorize the release of my medical/prescription information to my parent/guardian (for students over 18 years old).Full Name Date MM slash DD slash YYYY Student Name: School Attending: